Cycle 1
Health 2024-10-03 · Fire 2024-10-03
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Shawnee, OK
The Golden Rule Home
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
38801 Hardesty Road, Shawnee, OK
(405) 273-7106
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
83
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
2007-09-01
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.04% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 20.69% · Lower 95% interval 7.01% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · 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 12 · 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 21 · 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 49 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 52 |
| 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 3 · 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 | 2.9 |
2.3
0.6 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.9
0.3 pts better
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.7 · Expected 1.7 · Used in QM five-star |
| 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 | 97.2% |
94.6%
2.6 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
3.3%
2.5 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.6%
0.8 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 4.0% · Q4 3.4% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
25.3%
0.7 pts better
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 25.0% · Q3 29.6% · Q4 27.8% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.8% |
18.6%
17.2 pts worse
|
16.7%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 34.8% · Q3 36.4% · Q4 37.0% · 4Q avg 35.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 3.8% |
0.1%
3.7 pts worse
|
0.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.9% · Q3 6.5% · Q4 2.7% · 4Q avg 3.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.8% |
15.5%
4.7 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
14.1%
2.6 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.7% · Q3 17.4% · Q4 28.1% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
2.1%
1.9 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.1% · Q3 3.8% · Q4 4.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.8%
0.3 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.4% |
17.8%
10.4 pts better
|
19.8%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 6.1% · Q3 0.0% · Q4 13.3% · 4Q avg 7.4% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.1%
0.6 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.6% · Q3 4.4% · Q4 6.5% · 4Q avg 5.7% · 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 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
17.1%
9.8 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 8.3% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
27.0%
2.2 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 29.2% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-01
F · Potential for more than minimal harm
2023-09-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-06
F · Potential for more than minimal harm
2022-09-01
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-10-14
F · Potential for more than minimal harm
2022-09-01
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
2022-09-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-03
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 2024-11-01
E · Potential for more than minimal harm
2024-10-03
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 2024-11-01
D · Potential for more than minimal harm
2024-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-03
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 2024-11-01
E · Potential for more than minimal harm
2024-08-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-13
J · Immediate jeopardy
2023-09-07
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 2023-06-09
E · Potential for more than minimal harm
2023-09-07
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 2023-10-16
E · Potential for more than minimal harm
2023-09-07
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 2023-10-16
E · Potential for more than minimal harm
2023-09-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-07
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 2023-10-16
D · Potential for more than minimal harm
2023-09-07
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 2023-10-16
D · Potential for more than minimal harm
2023-09-07
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 2023-10-16
D · Potential for more than minimal harm
2023-09-07
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 2023-10-16
F · Potential for more than minimal harm
2022-09-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-01
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 2022-10-14
E · Potential for more than minimal harm
2022-09-01
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 2022-10-14
E · Potential for more than minimal harm
2022-09-01
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 2022-10-14
E · Potential for more than minimal harm
2022-09-01
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-01
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 2022-10-14
E · Potential for more than minimal harm
2022-09-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-01
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 2022-10-14
Penalties and ownership
What sits behind the stars
$10,246
2023-09-07
Fine
Fine · fine $10,246
Fine
Ownership
Daves, William
5% Or Greater Direct Ownership Interest · Individual
Daves, Casey
Corporate Director · Individual
Daves, Casey
W-2 Managing Employee · Individual
Daves, William
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Heritage Skilled Nursing And Therapy
Tecumseh, OK
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
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
#3
Shawnee Care Center
Shawnee, OK
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
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