Cycle 1
Health 2025-01-30 · Fire 2025-01-30
15 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Norman, OK
Medical Park West Rehabilitation & Skilled Care
1-star overall rating with 1-star inspections with Special Focus status with $21,962 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3110 Healthplex Drive, Norman, OK
(405) 321-2188
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
94
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Stonegate Senior Living
Operator or chain grouping
Approved since
2012-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing
LPN hours / resident day
1.06
Licensed practical nurse staffing
Aide hours / resident day
2.32
Nurse aide staffing
Weekend hours
3.22
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.3
1.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.9
1.3 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
90.3%
9.3 pts better
|
93.4%
6.2 pts better
|
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 | 4.9% |
4.5%
0.4 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 6.4% |
3.6%
2.8 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
25.3%
5.5 pts better
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
18.6%
12 pts better
|
16.7%
10.1 pts better
|
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 | 14.0% |
15.5%
1.5 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
14.1%
4.7 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
2.1%
0.8 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.8%
2.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.9% |
17.8%
7.9 pts better
|
19.8%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 14.0% |
5.1%
8.9 pts worse
|
5.1%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.5% |
75.0%
9.5 pts better
|
81.7%
2.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
17.1%
3.2 pts better
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.9%
1.1 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
74.0%
16.3 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
27.0%
0.8 pts better
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-07 · Fire 2023-11-07
23 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-10-04 · Fire 2022-10-04
18 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-30
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 2025-02-27
E · Potential for more than minimal harm
2025-01-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-30
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 2025-02-27
F · Potential for more than minimal harm
2023-11-07
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 2024-03-04
C · Minimal harm
2023-11-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-04
E · Potential for more than minimal harm
2022-10-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-04
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 2022-11-08
C · Minimal harm
2022-10-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-09
K · Immediate jeopardy
2025-07-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-24
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-09
E · Potential for more than minimal harm
2025-01-30
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 2025-02-27
E · Potential for more than minimal harm
2025-01-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-30
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-30
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 2025-02-27
D · Potential for more than minimal harm
2025-01-30
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 2025-02-27
D · Potential for more than minimal harm
2025-01-30
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-30
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 2025-02-27
D · Potential for more than minimal harm
2025-01-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-04-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-26
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 2024-05-15
D · Potential for more than minimal harm
2024-04-26
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 2024-05-15
D · Potential for more than minimal harm
2024-01-18
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 2024-01-29
J · Immediate jeopardy
2023-11-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-06
G · Actual harm
2023-11-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-07
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-07
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 2023-12-06
E · Potential for more than minimal harm
2023-11-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
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 2023-12-06
D · Potential for more than minimal harm
2023-11-07
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 2023-12-06
D · Potential for more than minimal harm
2023-11-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-08-08
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 2023-08-31
E · Potential for more than minimal harm
2023-05-15
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 2023-06-09
D · Potential for more than minimal harm
2023-05-15
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 2023-06-09
D · Potential for more than minimal harm
2023-05-15
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 2023-06-09
E · Potential for more than minimal harm
2023-03-09
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 2023-04-07
E · Potential for more than minimal harm
2023-03-09
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 2023-04-07
D · Potential for more than minimal harm
2023-03-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-09
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 2023-04-07
D · Potential for more than minimal harm
2023-03-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-07
E · Potential for more than minimal harm
2022-10-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-04
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 2022-11-08
E · Potential for more than minimal harm
2022-10-04
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 2022-11-08
E · Potential for more than minimal harm
2022-10-04
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-04
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 2022-11-08
E · Potential for more than minimal harm
2022-10-04
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-04
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 2022-11-08
E · Potential for more than minimal harm
2022-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-17
Penalties and ownership
What sits behind the stars
$21,962
2023-11-07
Fine
Fine · fine $21,962
Fine
Ownership
Preservation Freehold Company
5% Or Greater Indirect Ownership Interest · Organization
Chance, James
Operational/Managerial Control · Individual
Pf Mpw SNF Ops LLC
5% Or Greater Direct Ownership Interest · Organization
Pf Mpw SNF Ops LLC
Operational/Managerial Control · Organization
Reid, Sherry
Operational/Managerial Control · Individual
Sanctuary Ltc, LLC
5% Or Greater Direct Ownership Interest · Organization
Smith, Antoine
Operational/Managerial Control · Individual
Stonegate Senior Living, LP
Operational/Managerial Control · Organization
Taylor, John
Operational/Managerial Control · Individual
Umb Bank Na
5% Or Greater Mortgage Interest · Organization
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#3
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