Cycle 1
Health 2024-08-07 · Fire 2024-08-07
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hennessey, OK
Hennessey Nursing & Rehab
2-star overall rating with 2-star inspections with $33,924 in total fines with 13 recent health deficiencies
705 East 3rd Street, Hennessey, OK
(405) 853-4390
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bradford Montgomery
Operator or chain grouping
Approved since
2005-08-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing
LPN hours / resident day
1.24
Licensed practical nurse staffing
Aide hours / resident day
3.37
Nurse aide staffing
Weekend hours
4.30
Weekend nurse staffing
RN turnover
80%
Annual RN turnover
Total nurse turnover
80%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
90.3%
2.4 pts worse
|
93.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
4.5%
2.8 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 12.2% |
3.3%
8.9 pts worse
|
11.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.5% |
3.6%
4.9 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
25.3%
2.7 pts better
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
18.6%
1.4 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.9% |
15.5%
7.6 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
14.1%
1.1 pts worse
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.2% |
2.1%
4.1 pts worse
|
1.0%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.8%
2.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.4% |
17.8%
4.4 pts better
|
19.8%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
5.1%
4.3 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.2% |
75.0%
37.8 pts worse
|
81.7%
44.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-06 · Fire 2023-07-06
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-07 · Fire 2021-12-07
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-02
E · Potential for more than minimal harm
2021-12-07
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 2022-01-02
E · Potential for more than minimal harm
2021-12-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-07
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 2024-09-09
E · Potential for more than minimal harm
2024-08-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
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 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
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 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-07
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 2024-09-09
D · Potential for more than minimal harm
2024-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-09
J · Immediate jeopardy
2024-04-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-30
G · Actual harm
2024-04-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-15
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-15
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 2024-04-30
E · Potential for more than minimal harm
2023-07-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-07-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-06
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 2023-08-14
D · Potential for more than minimal harm
2023-07-06
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 2023-08-14
D · Potential for more than minimal harm
2023-07-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-05-08
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 2023-06-09
E · Potential for more than minimal harm
2021-12-07
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 2022-01-02
E · Potential for more than minimal harm
2021-12-07
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 2022-01-02
Penalties and ownership
What sits behind the stars
$33,924
2024-04-15
Fine
Fine · fine $33,924
Fine
Ownership
Montgomery, Bradford
5% Or Greater Direct Ownership Interest · Individual
Torson, Julie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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2-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Greenbrier Village Health and Rehabilitation
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3-star overall rating with 3-star inspections with $14,819 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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