Cycle 1
Health 2024-11-20 · Fire 2024-11-20
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ponca City, OK
Shawn Manor Nursing Home
5-star overall rating with 5-star inspections with 3 recent health deficiencies
2024 Turner Road, Ponca City, OK
(580) 765-3364
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Conhold
Operator or chain grouping
Approved since
1995-01-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 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
0.33
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.09
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,089
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
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
2.14
Performance 7.20% · Measure score 2.14 · Achievement 2.14 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.82
Baseline 3.61 hours · Performance 3.88 hours · Measure score 2.82 · Achievement 2.82 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 14.29% · Lower 95% interval 6.69% |
| Discharge to community | 49.58% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 45.95% · Lower 95% interval 35.14% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 10 · Denominator 20 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 10 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 32 |
| Staff flu vaccination coverage | 8.57% |
42%
33.4 pts worse
|
Numerator 3 · Denominator 35 |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 11 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
94.6%
0.6 pts better
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.5%
4.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.6%
3.6 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
25.3%
5 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
18.6%
12.5 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.1% |
15.5%
9.4 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
14.1%
7.9 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · 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% · 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 | 6.5% |
17.8%
11.3 pts better
|
19.8%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 9.3% · 4Q avg 6.5% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.1%
3.6 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q4 0.0% · 4Q avg 1.5% · 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
17.1%
3.7 pts better
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.5% · Expected 10.4% · 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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
74.0%
22.8 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
27.0%
2.8 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 28.1% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-09-09
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 2022-10-24
E · Potential for more than minimal harm
2022-09-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
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 2022-10-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-11-20
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-16
E · Potential for more than minimal harm
2023-11-02
F571 · Resident Rights Deficiencies
Health
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-02
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 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
H · Actual harm
2022-09-09
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 2022-10-24
H · Actual harm
2022-09-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-10-24
H · Actual harm
2022-09-09
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 2022-10-24
H · Actual harm
2022-09-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
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 2022-10-24
E · Potential for more than minimal harm
2022-09-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
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 2022-10-24
E · Potential for more than minimal harm
2022-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-09
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 2022-10-24
D · Potential for more than minimal harm
2022-09-09
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 2022-10-24
D · Potential for more than minimal harm
2022-09-09
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-10-24
Penalties and ownership
What sits behind the stars
Ownership
Sullivan, James
5% Or Greater Direct Ownership Interest · Individual
Allred, Amy
Operational/Managerial Control · Individual
Conhold Of Ponca LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Bradbury Commons
Ponca City, OK
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Ponca City Nursing & Rehabilitation Center
Ponca City, OK
5-star overall rating with 5-star inspections with 3 recent health deficiencies
#3
Hillcrest Manor Nursing Center
Blackwell, OK
1-star overall rating with 2-star inspections with $46,898 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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