Cycle 1
Health 2024-10-31 · Fire 2024-10-31
3 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Enid, OK
The Commons
4-star overall rating with 4-star inspections with $3,174 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
301 South Oakwood Road, Enid, OK
(580) 237-6164
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
138
Certified beds
Average residents
84
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-02-09
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
0.29
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.20
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
0.37
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.09
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
2,685
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.29
Composite VBP score used to determine payment impact.
Payment multiplier
1.0020
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.60
Baseline 20.27% · Performance 18.84% · Measure score 5.60 · Achievement 5.60 · Improvement 3.92
Healthcare-associated infections
7.98
Baseline 6.12% · Performance 5.45% · Measure score 7.98 · Achievement 7.98 · Improvement 5.47
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
0.91
Baseline 3.20 hours · Performance 3.34 hours · Measure score 0.91 · Achievement 0.91 · Improvement 0.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.27% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 173 · Observed rate 4.62% · Lower 95% interval 5.48% |
| Discharge to community | 58.86% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 158 · Observed rate 58.23% · Lower 95% interval 49.57% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 91 · Denominator 91 |
| Falls with major injury | 4.4% |
0.77%
3.6 pts worse
|
Numerator 4 · Denominator 91 |
| Discharge self-care score | 59.68% |
53.69%
6 pts better
|
Numerator 37 · Denominator 62 |
| Discharge mobility score | 56.45% |
50.94%
5.5 pts better
|
Numerator 35 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 4.4% |
2.29%
2.1 pts worse
|
Numerator 4 · Denominator 91 · Adjusted rate 5.65% |
| Healthcare-associated infections requiring hospitalization | 5.45% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 2.52% · Lower 95% interval 3.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 16.08% |
42%
25.9 pts worse
|
Numerator 59 · Denominator 367 |
| Discharge function score | 59.68% |
56.45%
3.2 pts better
|
Numerator 37 · Denominator 62 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.36% |
96.28%
0.1 pts better
|
Numerator 53 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 34.09% |
25.2%
8.9 pts better
|
Numerator 15 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.4 |
2.9
1.5 pts worse
|
1.8
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 4.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
90.3%
9 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 13.7% |
4.5%
9.2 pts worse
|
3.3%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 16.2% · Q3 11.4% · Q4 4.3% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
3.3%
0.7 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.4% · Q3 1.6% · Q4 3.1% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
3.6%
2.4 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 1.7% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.8% |
25.3%
9.5 pts worse
|
19.6%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 39.7% · Q3 32.3% · Q4 30.2% · 4Q avg 34.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.3% |
18.6%
2.7 pts worse
|
16.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · Q3 21.6% · Q4 23.5% · 4Q avg 21.3% · 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 | 6.8% |
15.5%
8.7 pts better
|
16.3%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
14.1%
7 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 3.3% · Q3 1.6% · Q4 5.0% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.1%
0.9 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.8%
0.4 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.4% · Q3 2.9% · Q4 3.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
17.8%
7.1 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 24.7% · Q3 25.4% · Q4 21.0% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.1%
1.9 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.6% · Q3 0.0% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
75.0%
21.7 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 96.2% · Q3 100.0% · Q4 100.0% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.9% |
17.1%
1.8 pts worse
|
12.0%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 17.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.9%
0.2 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.7% · Q3 1.9% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.9% |
74.0%
19.9 pts better
|
79.7%
14.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
27.0%
1.4 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 27.1% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-15 · Fire 2023-09-15
9 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-08-24 · Fire 2022-08-24
12 health deficiencies
Top issue: Administration (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-31
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 2024-12-13
E · Potential for more than minimal harm
2024-10-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-13
F · Potential for more than minimal harm
2023-09-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-26
F · Potential for more than minimal harm
2023-09-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-26
E · Potential for more than minimal harm
2022-08-24
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 2022-09-27
E · Potential for more than minimal harm
2022-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-27
E · Potential for more than minimal harm
2022-08-24
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 2022-09-27
E · Potential for more than minimal harm
2022-08-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-31
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 2024-11-19
E · Potential for more than minimal harm
2024-10-31
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 2024-11-19
E · Potential for more than minimal harm
2024-10-31
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 2024-11-19
E · Potential for more than minimal harm
2023-09-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-09-15
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 2023-11-03
D · Potential for more than minimal harm
2023-09-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-15
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-15
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 2023-11-03
D · Potential for more than minimal harm
2023-09-15
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 2023-11-03
D · Potential for more than minimal harm
2023-09-15
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-15
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 2023-11-03
D · Potential for more than minimal harm
2023-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-03-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-31
J · Immediate jeopardy
2022-08-24
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 2022-09-27
F · Potential for more than minimal harm
2022-08-24
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-09-27
F · Potential for more than minimal harm
2022-08-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-27
E · Potential for more than minimal harm
2022-08-24
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 2022-09-27
E · Potential for more than minimal harm
2022-08-24
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 2022-09-27
E · Potential for more than minimal harm
2022-08-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-27
E · Potential for more than minimal harm
2022-08-24
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 2022-09-27
E · Potential for more than minimal harm
2022-08-24
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 2022-09-27
E · Potential for more than minimal harm
2022-08-24
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-09-27
E · Potential for more than minimal harm
2022-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-27
D · Potential for more than minimal harm
2022-08-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-27
Penalties and ownership
What sits behind the stars
$3,174
2023-11-06
Fine
Fine · fine $3,174
Fine
Ownership
Nearby options
Other facilities in reach
#1
Garland Road Nursing & Rehab Center
Enid, OK
1-star overall rating with 1-star inspections with Special Focus status with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Greenbrier Village Health and Rehabilitation
Enid, OK
3-star overall rating with 3-star inspections with $14,819 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Baptist Village Of Enid
Enid, OK
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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