Cycle 1
Health 2024-07-10 · Fire 2024-07-10
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Yukon, OK
Gran Grans Place
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1110 South Cornwell Drive, Yukon, OK
(405) 350-2311
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
69
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-05-21
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
0.40
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,346
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.30
Baseline 4.55 hours · Performance 4.02 hours · Measure score 3.30 · Achievement 3.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.27% |
8.2%
5.9 pts worse
|
Numerator 1 · Denominator 44 |
| Staff flu vaccination coverage | 2.29% |
42%
39.7 pts worse
|
Numerator 5 · Denominator 218 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
2.3
2 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.9
2.5 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
90.3%
9 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.0% |
4.5%
5.5 pts worse
|
3.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 13.2% · Q3 8.8% · Q4 9.1% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.6% |
3.3%
9.3 pts worse
|
11.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 14.7% · Q3 15.6% · Q4 12.5% · 4Q avg 12.6% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
3.6%
About the same
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.3% · Q3 2.9% · Q4 3.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
25.3%
4.6 pts better
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 21.1% · Q3 20.6% · Q4 18.2% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
18.6%
3.1 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 12.9% · Q3 17.9% · Q4 15.4% · 4Q avg 15.5% · 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 | 3.1% |
15.5%
12.4 pts better
|
16.3%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
14.1%
6.4 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 18.8% · Q3 3.6% · Q4 3.7% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.8%
2.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.3% |
17.8%
13.5 pts better
|
19.8%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 10.5% · Q3 2.8% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.1%
0.7 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.5% · Q3 3.4% · Q4 3.0% · 4Q avg 5.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-23 · Fire 2023-06-23
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-03-23 · Fire 2022-03-23
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2024-07-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-10
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-10
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 2024-08-08
D · Potential for more than minimal harm
2024-07-10
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-10
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-08
D · Potential for more than minimal harm
2023-11-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-06-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-06-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-06-23
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-06-23
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-06-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-04
Penalties and ownership
What sits behind the stars
Ownership
Lusty, David
5% Or Greater Direct Ownership Interest · Individual
Lusty, Nell
5% Or Greater Direct Ownership Interest · Individual
Dye, Angela
Operational/Managerial Control · Individual
Lusty, Nell
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Spanish Cove Housing Authority
Yukon, OK
5-star overall rating with 5-star inspections with $8,018 in total fines with 1 recent health deficiencies
#2
Ranchwood Nursing Center
Yukon, OK
1-star overall rating with 1-star inspections with $67,525 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Heritage Park
Bethany, OK
1-star overall rating with 2-star inspections with $7,834 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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