Cycle 1
Health 2024-04-18 · Fire 2024-04-18
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pauls Valley, OK
Pauls Valley Care Center
1-star overall rating with 3-star inspections with $50,778 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1413 South Chickasaw Street, Pauls Valley, OK
(405) 238-6411
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
71
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-07-15
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
0.21
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
2.72
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,220
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
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
1.47
Baseline 82.86% · Performance 71.43% · Measure score 1.47 · Achievement 0 · Improvement 1.47
Adjusted total nurse staffing
4.02
Baseline 4.60 hours · Performance 4.22 hours · Measure score 4.02 · Achievement 4.02 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.32% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 6.08% |
| 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 | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · 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 15 · 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 13 · 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 33 |
| 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 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.3%
9.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.7% |
94.6%
7.9 pts worse
|
95.5%
8.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| 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 0.0% · Q2 0.0% · Q3 6.2% · Q4 11.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.3% |
3.3%
3 pts worse
|
11.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 8.0% · Q3 6.5% · Q4 0.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.6%
2.6 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 53.1% |
25.3%
27.8 pts worse
|
19.6%
33.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 50.0% · Q3 52.0% · Q4 60.0% · 4Q avg 53.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 37.3% |
18.6%
18.7 pts worse
|
16.7%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 35.0% · Q4 30.0% · 4Q avg 37.3% · 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 | 26.4% |
15.5%
10.9 pts worse
|
16.3%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
14.1%
8 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 29.2% · Q3 8.3% · Q4 25.0% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.1%
0.5 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 2.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.8%
2 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
17.8%
4.4 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 20.5% · Q3 16.0% · Q4 18.2% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.1%
2.4 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 3.2% · Q4 3.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
75.0%
22.2 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · 4Q avg 97.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.4% |
1.9%
5.5 pts worse
|
1.6%
5.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 16.7% |
74.0%
57.3 pts worse
|
79.7%
63 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 16.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-10 · Fire 2023-03-10
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
2 health deficiencies
Top issue: Infection Control (1 deficiency)
14 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-03
F · Potential for more than minimal harm
2023-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-03-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-03-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-06
C · Minimal harm
2023-03-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-06
F · Potential for more than minimal harm
2022-08-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-08-18
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 2022-10-15
F · Potential for more than minimal harm
2022-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-01
F · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-01
F · Potential for more than minimal harm
2022-08-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-15
F · Potential for more than minimal harm
2022-08-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-01
E · Potential for more than minimal harm
2022-08-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-08-23
E · Potential for more than minimal harm
2022-08-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-01
E · Potential for more than minimal harm
2022-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-08-18
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 2022-10-01
E · Potential for more than minimal harm
2022-08-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-01
E · Potential for more than minimal harm
2022-08-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-01
C · Minimal harm
2022-08-18
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 2022-10-13
Inspection history
Recent health citations
G · Actual harm
2025-12-18
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 2026-02-10
E · Potential for more than minimal harm
2024-04-18
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-06-08
E · Potential for more than minimal harm
2024-04-18
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 2024-05-10
E · Potential for more than minimal harm
2024-04-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-18
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 2024-05-10
E · Potential for more than minimal harm
2024-04-18
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 2024-05-10
D · Potential for more than minimal harm
2024-04-18
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-05-10
E · Potential for more than minimal harm
2023-03-10
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 2023-07-07
D · Potential for more than minimal harm
2023-03-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-03-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-03-10
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 2023-07-07
E · Potential for more than minimal harm
2022-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-25
D · Potential for more than minimal harm
2022-08-18
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 2022-09-18
Penalties and ownership
What sits behind the stars
$50,778
2024-04-18
Fine
Fine · fine $50,778
Fine
$0
2024-04-18
Payment Denial
Payment Denial · denial start 2024-06-27 · 28 days
28 day denial
Ownership
Smith, Brooke
5% Or Greater Direct Ownership Interest · Individual
Smith, Layne
5% Or Greater Direct Ownership Interest · Individual
Smith, Brooke
Corporate Officer · Individual
Smith, Layne
Corporate Officer · Individual
Smith, Layne
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Washita Valley Living Center
Pauls Valley, OK
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Burford Manor
Davis, OK
1-star overall rating with 2-star inspections with $17,767 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Callaway Nursing Home
Sulphur, OK
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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