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
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 2 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
0.54
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.37
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
5.15
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
4.30
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.31
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
0.67
CMS adjusted RN staffing hours
Adjusted total hours
6.37
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
80%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,986
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0000
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
3.96
Baseline 51.28% · Performance 47.50% · Measure score 3.96 · Achievement 3.96 · Improvement 0.93
Adjusted total nurse staffing
5.36
Baseline 3.64 hours · Performance 4.60 hours · Measure score 5.36 · Achievement 5.36 · Improvement 3.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · 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 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · 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 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 50 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · 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 | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 2.1 · 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 2.5 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 93.1% · Q2 89.3% · Q3 75.0% · Q4 93.5% · 4Q avg 87.9% |
| 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 | 1.7% |
4.5%
2.8 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.5% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 16.7% · Q2 17.4% · Q3 4.8% · Q4 10.0% · 4Q avg 12.2% |
| 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 · Q2 0.0% · Q3 9.5% · Q4 9.1% · 4Q avg 8.5% |
| 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 · Q1 25.0% · Q2 25.0% · Q3 18.2% · Q4 22.7% · 4Q avg 22.6% |
| 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 · 4Q avg 20.0% · 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 | 7.9% |
15.5%
7.6 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% · Used in QM five-star |
| 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 · Q1 15.0% · Q3 22.7% · Q4 5.0% · 4Q avg 15.2% · Used in QM five-star |
| 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 · Q1 6.2% · Q2 4.1% · Q3 7.9% · Q4 6.6% · 4Q avg 6.2% · Used in QM five-star |
| 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 · 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 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 · Q1 4.5% · Q2 13.4% · Q3 12.7% · Q4 22.6% · 4Q avg 13.4% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.8% · Used in QM five-star |
| 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 · 4Q avg 37.2% |
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
#1
Cimarron Nursing Center
Kingfisher, OK
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
First Shamrock Care Center
Kingfisher, OK
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
Enid, OK
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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