Cycle 1
Health 2025-04-21 · Fire 2025-04-21
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Midwest City, OK
Sienna Extended Care & Rehab
1-star overall rating with 2-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
9221 Harmony Drive, Midwest City, OK
(405) 869-0700
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-11-04
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
0.15
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.99
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
3.50
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.18
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.16
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
10,266
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.94
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
0
Baseline 24.29% · Performance 24.13% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.45
Baseline 11.65% · Performance 9.02% · Measure score 3.45 · Achievement 0 · Improvement 3.45
Total nurse turnover
2.64
Baseline 72.22% · Performance 57.33% · Measure score 2.64 · Achievement 1.55 · Improvement 2.64
Adjusted total nurse staffing
2.28
Baseline 2.99 hours · Performance 3.73 hours · Measure score 2.28 · Achievement 2.28 · Improvement 2.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.21% |
10.72%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 234 · Observed rate 15.81% · Lower 95% interval 9.95% |
| Discharge to community | 49.27% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 223 · Observed rate 44.39% · Lower 95% interval 43.46% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 90.67% |
95.27%
4.6 pts worse
|
Numerator 136 · Denominator 150 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 5 · Denominator 150 |
| Discharge self-care score | 55.06% |
53.69%
1.4 pts better
|
Numerator 49 · Denominator 89 |
| Discharge mobility score | 62.92% |
50.94%
12 pts better
|
Numerator 56 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 6 · Denominator 150 · Adjusted rate 4.45% |
| Healthcare-associated infections requiring hospitalization | 9.02% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 10.56% · Lower 95% interval 5.97% |
| Staff COVID-19 vaccination coverage | 65% |
8.2%
56.8 pts better
|
Numerator 26 · Denominator 40 |
| Staff flu vaccination coverage | 80% |
42%
38 pts better
|
Numerator 68 · Denominator 85 |
| Discharge function score | 56.18% |
56.45%
0.3 pts worse
|
Numerator 50 · Denominator 89 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 54 · Denominator 60 |
| Transfer of health information to patient | 93.1% |
96.28%
3.2 pts worse
|
Numerator 54 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 18.84% |
25.2%
6.4 pts worse
|
Numerator 13 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.9
1.2 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
90.3%
3.6 pts worse
|
93.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.2% · Q3 79.7% · Q4 71.9% · 4Q avg 86.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 69.7% |
94.6%
24.9 pts worse
|
95.5%
25.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 69.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
4.5%
1.5 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.5% · Q3 3.4% · Q4 5.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
3.3%
1.3 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.6% · Q3 2.0% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
3.6%
2.5 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
25.3%
8.6 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 11.8% · Q3 16.3% · Q4 18.4% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.3% |
18.6%
3.7 pts worse
|
16.7%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 22.2% · Q3 20.5% · Q4 20.5% · 4Q avg 22.3% · 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 | 8.2% |
15.5%
7.3 pts better
|
16.3%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
14.1%
0.2 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.0% · Q3 10.6% · Q4 8.3% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
2.1%
0.7 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 2.4% · Q4 1.3% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.8%
1.9 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 1.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
17.8%
7.8 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 34.8% · Q3 18.5% · Q4 23.5% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
5.1%
5.9 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 16.6% · Q3 11.3% · Q4 6.3% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
75.0%
13 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 85.7% · Q3 82.9% · Q4 83.5% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.3% |
17.1%
4.2 pts worse
|
12.0%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 21.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.9%
0.9 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.3% · Q3 4.7% · Q4 2.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
74.0%
7.9 pts better
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.9% |
27.0%
5.9 pts worse
|
23.9%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.9% · Observed 33.3% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-10 · Fire 2023-01-10
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-21
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 2025-05-30
F · Potential for more than minimal harm
2025-04-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-21
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 2025-05-30
E · Potential for more than minimal harm
2025-04-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-30
E · Potential for more than minimal harm
2023-01-10
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 2023-02-13
E · Potential for more than minimal harm
2023-01-10
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-21
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-21
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-21
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 2025-05-30
D · Potential for more than minimal harm
2025-04-21
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 2025-05-30
D · Potential for more than minimal harm
2025-04-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-21
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 2025-05-30
D · Potential for more than minimal harm
2025-04-21
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 2025-05-30
D · Potential for more than minimal harm
2025-04-21
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 2025-05-30
D · Potential for more than minimal harm
2024-02-08
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 2024-02-29
E · Potential for more than minimal harm
2023-12-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-12-21
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 2024-01-22
E · Potential for more than minimal harm
2023-12-21
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 2024-02-16
D · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-10-13
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-10-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-14
E · Potential for more than minimal harm
2023-10-13
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 2023-10-14
K · Immediate jeopardy
2023-01-10
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-02-13
G · Actual harm
2023-01-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-13
E · Potential for more than minimal harm
2023-01-10
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 2023-02-13
E · Potential for more than minimal harm
2023-01-10
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 2023-02-13
E · Potential for more than minimal harm
2023-01-10
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 2023-02-13
E · Potential for more than minimal harm
2023-01-10
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-02-13
E · Potential for more than minimal harm
2023-01-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-02-13
E · Potential for more than minimal harm
2023-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-13
D · Potential for more than minimal harm
2023-01-10
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 2023-02-13
D · Potential for more than minimal harm
2023-01-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-13
D · Potential for more than minimal harm
2023-01-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-13
Penalties and ownership
What sits behind the stars
Ownership
Montgomery, Bobbie
5% Or Greater Direct Ownership Interest · Individual
Montgomery, Schuyler
Operational/Managerial Control · Individual
Montgomery, Schuyler
Corporate Director · Individual
Sienna Extended Care & Rehab LLC
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Midwest City Post Acute & Rehab
Midwest City, OK
1-star overall rating with 2-star inspections with $31,011 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Emerald Care Center Midwest
Midwest City, OK
2-star overall rating with 2-star inspections with $4,017 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cross Timbers Nursing And Rehabilitation
Midwest City, OK
1-star overall rating with 1-star inspections with $178,463 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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