Cycle 1
Health 2024-12-19 · Fire 2024-12-19
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Chickasha, OK
Glenhaven Retirement Village
3-star overall rating with 3-star inspections with $14,433 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3003 Iowa, Chickasha, OK
(405) 224-0909
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.14
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.17
CMS adjusted RN staffing hours
Adjusted total hours
5.31
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
4,991
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.16
Performance 20.89% · Measure score 1.16 · Achievement 1.16 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.09
Baseline 6.59% · Performance 6.91% · Measure score 3.09 · Achievement 3.09 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.09
Baseline 4.33 hours · Performance 5.10 hours · Measure score 7.09 · Achievement 7.09 · Improvement 4.78
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.26% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 10% · Lower 95% interval 7.13% |
| Discharge to community | 61.91% |
50.57%
11.3 pts better
|
Better than the National Rate · Eligible stays 75 · Observed rate 66.67% · Lower 95% interval 51.82% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.33% |
95.27%
3.1 pts better
|
Numerator 59 · Denominator 60 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 2 · Denominator 60 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 28 · Denominator 42 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 28 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 60 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 10% |
8.2%
1.8 pts better
|
Numerator 6 · Denominator 60 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 76.19% |
56.45%
19.7 pts better
|
Numerator 32 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 2 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.9
0.9 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
90.3%
8.8 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.9% · Q3 100.0% · Q4 98.4% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.6%
3.5 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 14.6% |
4.5%
10.1 pts worse
|
3.3%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 16.7% · Q3 11.1% · Q4 14.5% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
3.3%
0.2 pts worse
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.4% · Q3 3.8% · Q4 1.8% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
3.6%
4.4 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.3% · Q3 5.4% · Q4 9.5% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.9% |
25.3%
10.6 pts worse
|
19.6%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.7% · Q2 40.0% · Q3 35.1% · Q4 31.8% · 4Q avg 35.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.5% |
18.6%
4.9 pts worse
|
16.7%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 22.7% · Q3 25.8% · Q4 21.6% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.0% |
15.5%
16.5 pts worse
|
16.3%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 18.8% · 4Q avg 32.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
14.1%
6.4 pts worse
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 10.7% · Q3 22.9% · Q4 17.5% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.1%
0.4 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.7% · Q3 0.0% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 13.9% |
2.8%
11.1 pts worse
|
1.7%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 8.5% · Q3 18.5% · Q4 16.7% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
17.8%
8.9 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 35.4% · Q3 19.3% · Q4 22.5% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.1%
1.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.0% · Q3 0.0% · Q4 7.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
75.0%
14.1 pts better
|
81.7%
7.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 85.7% · Q3 89.1% · Q4 90.9% · 4Q avg 89.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.3% |
17.1%
3.2 pts worse
|
12.0%
8.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 21.4% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.9%
0.5 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.0% |
74.0%
9 pts better
|
79.7%
3.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
27.0%
0.6 pts better
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 23.2% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-28
F · Potential for more than minimal harm
2023-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-17
E · Potential for more than minimal harm
2023-10-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-17
E · Potential for more than minimal harm
2023-10-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-12-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-17
J · Immediate jeopardy
2024-10-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-10-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-10-12
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-12
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-12-05
G · Actual harm
2022-12-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-03
E · Potential for more than minimal harm
2022-12-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-08
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-03
Penalties and ownership
What sits behind the stars
$14,433
2024-09-05
Fine
Fine · fine $14,433
Fine
$0
2024-09-05
Payment Denial
Payment Denial · denial start 2024-11-12 · 3 days
3 day denial
Ownership
Hamilton, Glenda
5% Or Greater Direct Ownership Interest · Individual
Hamilton, Glenda
Operational/Managerial Control · Individual
Hamilton, Glenda
Corporate Director · Individual
Lance, Billy
5% Or Greater Direct Ownership Interest · Individual
Lance, Billy
Corporate Director · Individual
Mason, Michael
5% Or Greater Direct Ownership Interest · Individual
Mason, Michael
Corporate Director · Individual
Mason, Patrick
5% Or Greater Direct Ownership Interest · Individual
Mason, Patrick
Corporate Director · Individual
Trett, Jenny
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Cottonwood Creek Skilled Nursing & Therapy
Chickasha, OK
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Shanoan Springs Nursing And Rehabilitation
Chickasha, OK
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Chickasha Nursing Center, Inc
Chickasha, OK
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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