Cycle 1
Health 2024-06-12 · Fire 2024-06-12
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Grove, OK
Grand Lake Villa
5-star overall rating with 5-star inspections with 1 recent health deficiencies
103 Har-Ber Road, Grove, OK
(918) 786-2276
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marsh Pointe Management
Operator or chain grouping
Approved since
1992-01-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 5 staffing / 3 quality stars
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
0.76
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.29
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.80
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
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,956
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9949
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.82
Baseline 19.43% · Performance 19.20% · Measure score 4.82 · Achievement 4.82 · Improvement 0.44
Healthcare-associated infections
0
Baseline 5.05% · Performance 8.24% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.84
Performance 35.71% · Measure score 6.84 · Achievement 6.84 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.13
Baseline 4.52 hours · Performance 4.54 hours · Measure score 5.13 · Achievement 5.13 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 106 · Observed rate 10.38% · Lower 95% interval 7.24% |
| Discharge to community | 55.8% |
50.57%
5.2 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 51.85% · Lower 95% interval 45.62% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 79 · Denominator 79 |
| Falls with major injury | 2.53% |
0.77%
1.8 pts worse
|
Numerator 2 · Denominator 79 |
| Discharge self-care score | 81.48% |
53.69%
27.8 pts better
|
Numerator 44 · Denominator 54 |
| Discharge mobility score | 70.37% |
50.94%
19.4 pts better
|
Numerator 38 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 5.06% |
2.29%
2.8 pts worse
|
Numerator 4 · Denominator 79 · Adjusted rate 5.18% |
| Healthcare-associated infections requiring hospitalization | 8.24% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 9.84% · Lower 95% interval 5.09% |
| Staff COVID-19 vaccination coverage | 1.98% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 101 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 74.07% |
56.45%
17.6 pts better
|
Numerator 40 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 44.74% |
25.2%
19.5 pts better
|
Numerator 17 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.9
0.7 pts better
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
90.3%
8.3 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.6%
3.8 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.3% |
4.5%
3.8 pts worse
|
3.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 10.3% · Q3 9.4% · Q4 5.7% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.3%
3.3 pts better
|
11.4%
11.4 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 who lose too much weight | 1.5% |
3.6%
2.1 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.9% |
25.3%
4.6 pts worse
|
19.6%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 33.3% · Q3 27.3% · Q4 31.0% · 4Q avg 29.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
18.6%
0.7 pts better
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 19.2% · Q3 14.8% · Q4 20.0% · 4Q avg 17.9% · 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 | 11.7% |
15.5%
3.8 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 20.8% · Q3 9.2% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
14.1%
0.6 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 13.9% · Q3 18.2% · Q4 10.3% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.1%
1.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.8%
1.4 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
17.8%
9.6 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 18.7% · Q3 23.5% · Q4 44.5% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
5.1%
4.6 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
75.0%
17.2 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 89.7% · Q3 94.2% · Q4 95.7% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
17.1%
1 pts better
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 16.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.9%
0.6 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.6% |
74.0%
14.6 pts better
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
27.0%
3.7 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 19.7% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-05 · Fire 2023-05-05
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-05-30 · Fire 2019-05-30
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-05-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-05-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-05-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-21
C · Minimal harm
2023-05-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-21
C · Minimal harm
2023-05-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-21
E · Potential for more than minimal harm
2019-05-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-06-30
E · Potential for more than minimal harm
2019-05-30
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2019-06-30
E · Potential for more than minimal harm
2019-05-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-06-30
C · Minimal harm
2019-05-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-06-30
C · Minimal harm
2019-05-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-06-30
C · Minimal harm
2019-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-27
D · Potential for more than minimal harm
2024-07-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-13
E · Potential for more than minimal harm
2023-05-05
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 2023-07-03
D · Potential for more than minimal harm
2023-05-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-03
D · Potential for more than minimal harm
2023-05-05
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 2023-07-03
D · Potential for more than minimal harm
2023-05-05
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 2023-07-03
E · Potential for more than minimal harm
2019-05-30
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2019-06-30
E · Potential for more than minimal harm
2019-05-30
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 2019-06-30
E · Potential for more than minimal harm
2019-05-30
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 2019-09-13
E · Potential for more than minimal harm
2019-05-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-30
E · Potential for more than minimal harm
2019-05-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-06-30
E · Potential for more than minimal harm
2019-05-30
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 2019-06-30
E · Potential for more than minimal harm
2019-05-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-10-21
E · Potential for more than minimal harm
2019-05-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-06-30
D · Potential for more than minimal harm
2019-05-30
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-06-30
D · Potential for more than minimal harm
2019-05-30
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 2019-06-30
Penalties and ownership
What sits behind the stars
Ownership
Brogdon, Connie
5% Or Greater Indirect Ownership Interest · Individual
Oklahoma Operating LLC
5% Or Greater Direct Ownership Interest · Organization
Oklahoma Financial LLC
5% Or Greater Direct Ownership Interest · Organization
Brogdon, Christopher
Operational/Managerial Control · Individual
Brogdon, Christopher
Corporate Officer · Individual
Marsh Pointe Management LLC
Operational/Managerial Control · Organization
Nichols, Cheryl
Operational/Managerial Control · Individual
Nichols, Cheryl
Corporate Officer · Individual
Tidwell, Richard
Operational/Managerial Control · Individual
Nearby options
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#2
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Grove, OK
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Monroe Manor
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2-star overall rating with 2-star inspections with $31,773 in total fines with 5 recent health deficiencies
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