Cycle 1
Health 2025-05-08 · Fire 2025-05-08
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Henryetta, OK
Henryetta Community Skilled Healthcare & Rehab
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
212 North Antes, Henryetta, OK
(918) 652-8797
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
53
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
2016-11-28
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
0.56
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.10
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
1.25
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
4.34
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.35
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
0.76
CMS adjusted RN staffing hours
Adjusted total hours
5.92
CMS adjusted total nurse staffing hours
Case-mix index
1.01
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,932
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
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
0
Baseline 43.33% · Performance 63.89% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.67
Performance 4.69 hours · Measure score 5.67 · Achievement 5.67 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.53% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 6.05% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 12 · Denominator 21 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 14 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 7.41% |
2.29%
5.1 pts worse
|
Numerator 2 · Denominator 27 · Adjusted rate 7.39% |
| 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 51 |
| Staff flu vaccination coverage | 2% |
42%
40 pts worse
|
Numerator 1 · Denominator 50 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 14 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 4.1 |
2.3
1.8 pts worse
|
1.9
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 3.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 6.3 |
2.9
3.4 pts worse
|
1.8
4.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 6.3 · Observed 6.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
90.3%
7.3 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 96.8% · Q3 100.0% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
94.6%
2.6 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
4.5%
0.3 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.2% · Q3 3.4% · Q4 6.2% · 4Q avg 4.8% · 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 | 4.0% |
3.6%
0.4 pts worse
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 8.0% · Q4 3.6% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.0% |
25.3%
4.3 pts better
|
19.6%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 19.2% · Q3 20.0% · Q4 17.9% · 4Q avg 21.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.4% |
18.6%
6.8 pts worse
|
16.7%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.4% · 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 | 21.6% |
15.5%
6.1 pts worse
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.2% |
14.1%
11.1 pts worse
|
14.9%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 15.4% · Q3 12.5% · Q4 40.7% · 4Q avg 25.2% · 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 6.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
2.8%
3 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 3.4% · Q4 12.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
17.8%
0.5 pts better
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 12.8% · Q3 19.4% · Q4 16.7% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 9.6% |
5.1%
4.5 pts worse
|
5.1%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.9% · Q3 13.4% · Q4 7.8% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
75.0%
25 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.3% |
17.1%
7.2 pts worse
|
12.0%
12.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 30.0% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
27.0%
1 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 30.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-31 · Fire 2022-10-31
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-25
F · Potential for more than minimal harm
2022-10-31
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-12-26
F · Potential for more than minimal harm
2022-10-31
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-12-26
F · Potential for more than minimal harm
2022-10-31
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-10-31
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-10-31
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 2022-12-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-18
E · Potential for more than minimal harm
2022-10-31
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 2022-12-26
E · Potential for more than minimal harm
2022-10-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-10-31
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 2022-12-26
E · Potential for more than minimal harm
2022-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-10-31
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-10-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-10-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-10-31
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-10-31
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 2022-12-26
D · Potential for more than minimal harm
2022-10-31
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 2022-12-26
Penalties and ownership
What sits behind the stars
Ownership
Majors, Cynthia
5% Or Greater Indirect Ownership Interest · Individual
Simmons, Charles
5% Or Greater Indirect Ownership Interest · Individual
Simmons, Donna
5% Or Greater Indirect Ownership Interest · Individual
The Charles Edward Simmons Revocable Trust Dated April 1, 2015
5% Or Greater Direct Ownership Interest · Organization
The Cynthia Denise Majors Revocable Trust Dated December 17, 2012
5% Or Greater Direct Ownership Interest · Organization
The Donna Renee Simmons Revocable Trust Dated December 17, 2012
5% Or Greater Direct Ownership Interest · Organization
Maxwell Utter, Judith
W-2 Managing Employee · Individual
Simmons, Donna
W-2 Managing Employee · Individual
True North Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Fountain View Manor, Inc
Henryetta, OK
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Highland Park Health Care
Okmulgee, OK
2-star overall rating with 2-star inspections with abuse icon flag with $13,397 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Woodlands Skilled Nursing And Therapy
Okmulgee, OK
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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