Cycle 1
Health 2024-07-10 · Fire 2024-07-10
23 health deficiencies
Top issue: Resident Rights (8 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Shawnee, OK
Shawnee Care Center
1-star overall rating with 1-star inspections with $22,393 in total fines with 23 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1202 West Gilmore, Shawnee, OK
(405) 273-8043
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bgm Estate
Operator or chain grouping
Approved since
1995-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 2 overall / 3 health / 3 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
0.89
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.29
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
0.48
CMS adjusted RN staffing hours
Adjusted total hours
4.67
CMS adjusted total nurse staffing hours
Case-mix index
1.06
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,206
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.27
Performance 19.45% · Measure score 4.27 · Achievement 4.27 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.11
Performance 7.20% · Measure score 2.11 · Achievement 2.11 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 38.78% · Performance 72.22% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.07
Baseline 3.24 hours · Performance 3.67 hours · Measure score 2.07 · Achievement 2.07 · Improvement 1.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 6.98% · Lower 95% interval 5.97% |
| Discharge to community | 58.84% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 60% · Lower 95% interval 45.98% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 61 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 65 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · 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 |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.9
0.8 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
90.3%
8.6 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 97.9% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 2.3% · Q2 6.4% · Q3 6.4% · Q4 4.3% · 4Q avg 4.9% · 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 | 7.8% |
3.6%
4.2 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 10.8% · Q3 7.7% · Q4 7.3% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
25.3%
12.5 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 10.8% · Q3 10.3% · Q4 14.3% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
18.6%
1 pts worse
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 18.2% · Q3 23.3% · Q4 18.2% · 4Q avg 19.6% · 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 | 9.9% |
15.5%
5.6 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 5.3% · Q3 13.5% · Q4 9.6% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
14.1%
5.8 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 13.5% · Q3 5.1% · Q4 7.1% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.4% |
2.1%
3.3 pts worse
|
1.0%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.8% · Q3 5.4% · Q4 4.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.8%
About the same
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.5% · Q4 2.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.5% |
17.8%
7.3 pts better
|
19.8%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 11.0% · Q3 14.8% · Q4 6.3% · 4Q avg 10.5% |
| Percentage of long-stay residents with pressure ulcers | 11.1% |
5.1%
6 pts worse
|
5.1%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.6% · Q3 10.4% · Q4 16.6% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
75.0%
23.4 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 98.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-28 · Fire 2023-06-28
22 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-22 · Fire 2022-08-22
28 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-23
F · Potential for more than minimal harm
2024-07-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-23
E · Potential for more than minimal harm
2023-06-28
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 2023-09-15
E · Potential for more than minimal harm
2023-06-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-06-28
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 2023-09-15
C · Minimal harm
2023-06-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-15
C · Minimal harm
2023-06-28
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-15
F · Potential for more than minimal harm
2022-08-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
C · Minimal harm
2022-08-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-29
G · Actual harm
2025-05-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-23
G · Actual harm
2025-05-15
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-06-23
F · Potential for more than minimal harm
2025-05-15
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 2025-06-23
F · Potential for more than minimal harm
2025-05-15
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2025-06-23
E · Potential for more than minimal harm
2024-07-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-07-10
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 2024-09-23
E · Potential for more than minimal harm
2024-07-10
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 2024-09-23
E · Potential for more than minimal harm
2024-07-10
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 2024-09-23
E · Potential for more than minimal harm
2024-07-10
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 2024-09-23
E · Potential for more than minimal harm
2024-07-10
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 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-07-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-07-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-06-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-03-07
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
2024-03-07
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 2024-05-10
D · Potential for more than minimal harm
2024-03-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-10
F · Potential for more than minimal harm
2023-11-13
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 2024-01-05
F · Potential for more than minimal harm
2023-11-13
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 2024-01-05
E · Potential for more than minimal harm
2023-11-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-06-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-06-28
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 2023-08-10
E · Potential for more than minimal harm
2023-06-28
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 2023-08-10
E · Potential for more than minimal harm
2023-06-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-06-28
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-06-28
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 2023-08-10
E · Potential for more than minimal harm
2023-06-28
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 2023-08-10
E · Potential for more than minimal harm
2023-06-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-06-28
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-06-28
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 2023-08-10
E · Potential for more than minimal harm
2023-06-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-28
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-28
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 2023-08-10
D · Potential for more than minimal harm
2023-06-28
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 2023-08-10
D · Potential for more than minimal harm
2023-06-28
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 2023-08-10
D · Potential for more than minimal harm
2023-06-28
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 2023-08-10
D · Potential for more than minimal harm
2023-06-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-03-29
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 2023-04-14
D · Potential for more than minimal harm
2023-03-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-14
F · Potential for more than minimal harm
2022-08-22
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
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 2022-10-08
E · Potential for more than minimal harm
2022-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-08
E · Potential for more than minimal harm
2022-08-22
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-22
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 2022-10-08
D · Potential for more than minimal harm
2022-08-22
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-22
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 2022-10-08
D · Potential for more than minimal harm
2022-08-22
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 2022-10-08
D · Potential for more than minimal harm
2022-08-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-08
D · Potential for more than minimal harm
2022-08-22
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 2022-10-08
Penalties and ownership
What sits behind the stars
$22,393
2025-05-15
Fine
Fine · fine $22,393
Fine
$0
2024-06-26
Payment Denial
Payment Denial · denial start 2024-09-26 · 4 days
4 day denial
Ownership
Bgm Estate LLC
5% Or Greater Direct Ownership Interest · Organization
Gilbert F. Green Trust
5% Or Greater Direct Ownership Interest · Organization
Philip M. Green Revocable Trust
5% Or Greater Direct Ownership Interest · Organization
Mitchell, Kelly
5% Or Greater Direct Ownership Interest · Individual
Mitchell, Kelly
5% Or Greater Indirect Ownership Interest · Individual
Mitchell, Marcinda
5% Or Greater Indirect Ownership Interest · Individual
Mitchell, Robert
5% Or Greater Indirect Ownership Interest · Individual
Tabor, Angela
5% Or Greater Indirect Ownership Interest · Individual
Morgan, Michael
Corporate Officer · Individual
Taylor, Sandra
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Shawnee Colonial Estates Nursing Home
Shawnee, OK
1-star overall rating with 1-star inspections with $44,355 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Regency Skilled Nursing And Therapy
Shawnee, OK
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Golden Rule Home
Shawnee, OK
2-star overall rating with 3-star inspections with $10,246 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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