Cycle 1
Health 2024-08-14 · Fire 2024-08-14
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Jay, OK
Monroe Manor
2-star overall rating with 2-star inspections with $31,773 in total fines with 5 recent health deficiencies
226 E Monroe Street, Jay, OK
(918) 919-3276
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Global Healthcare Reit
Operator or chain grouping
Approved since
2002-09-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 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
0.37
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.42
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,899
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.7
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
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 60.98% · Performance 67.65% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.74
Baseline 4.01 hours · Performance 4.14 hours · Measure score 3.74 · Achievement 3.74 · Improvement 0.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 43 · Observed rate 11.63% · Lower 95% interval 7.11% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 90% |
95.27%
5.3 pts worse
|
Numerator 18 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 20% |
2.29%
17.7 pts worse
|
Numerator 4 · Denominator 20 · Adjusted rate 19.09% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · 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 58 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 110 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · 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 | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.9
0.3 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
90.3%
1.1 pts better
|
93.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 97.1% · Q3 90.9% · Q4 92.3% · 4Q avg 91.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
94.6%
2.3 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 13.6% |
4.5%
9.1 pts worse
|
3.3%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 17.1% · Q3 12.1% · Q4 12.8% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
3.3%
3.8 pts worse
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 18.8% · Q3 9.7% · Q4 0.0% · 4Q avg 7.1% |
| Percentage of long-stay residents who lose too much weight | 14.7% |
3.6%
11.1 pts worse
|
5.4%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 16.7% · Q3 4.5% · Q4 11.1% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
25.3%
4.6 pts better
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 17.9% · Q3 25.0% · Q4 16.7% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
18.6%
4.6 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 23.8% · Q3 28.6% · Q4 19.0% · 4Q avg 23.2% · 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 | 23.8% |
15.5%
8.3 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
14.1%
6.3 pts better
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 7.7% · Q3 0.0% · Q4 11.1% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.1%
1.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.5% |
2.8%
8.7 pts worse
|
1.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 13.3% · Q3 6.5% · Q4 11.1% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.1% |
17.8%
3.7 pts better
|
19.8%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 16.2% · Q3 24.1% · Q4 10.5% · 4Q avg 14.1% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
5.1%
3.5 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.4% |
75.0%
9.6 pts worse
|
81.7%
16.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 60.0% · Q3 52.0% · 4Q avg 65.4% |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-14 · Fire 2023-07-14
8 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-04-09 · Fire 2021-04-09
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-07-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-07-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-08
F · Potential for more than minimal harm
2021-04-09
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2021-05-05
E · Potential for more than minimal harm
2021-04-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-05
E · Potential for more than minimal harm
2021-04-09
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 2021-05-05
Inspection history
Recent health citations
J · Immediate jeopardy
2024-09-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-21
G · Actual harm
2024-09-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-08-14
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 2024-10-04
E · Potential for more than minimal harm
2024-08-14
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 2024-10-04
E · Potential for more than minimal harm
2024-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-14
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 2024-10-04
D · Potential for more than minimal harm
2024-08-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-07-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-05-28
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 2024-06-06
D · Potential for more than minimal harm
2024-05-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-06
D · Potential for more than minimal harm
2024-01-30
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 2024-02-23
G · Actual harm
2024-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-01-23
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 2024-02-15
D · Potential for more than minimal harm
2024-01-23
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-02-13
E · Potential for more than minimal harm
2023-07-14
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 2023-08-25
D · Potential for more than minimal harm
2023-07-14
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 2023-08-25
E · Potential for more than minimal harm
2021-04-09
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 2021-05-05
Penalties and ownership
What sits behind the stars
$23,755
2024-07-23
Fine
Fine · fine $23,755
Fine
$8,018
2024-01-23
Fine
Fine · fine $8,018
Fine
$0
2024-01-23
Payment Denial
Payment Denial · denial start 2024-02-15 · 8 days
8 day denial
Ownership
Rhine, Zvi
5% Or Greater Indirect Ownership Interest · Individual
Tlc Eretz Management LLC
5% Or Greater Direct Ownership Interest · Organization
Matheson, Orrise
W-2 Managing Employee · Individual
Rhine, Zvi
Operational/Managerial Control · Individual
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 1 recent health deficiencies
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