Cycle 1
Health 2024-11-21 · Fire 2024-11-21
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Oklahoma City, OK
The Lakes
1-star overall rating with 2-star inspections with $19,073 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5701 West Britton Road, Oklahoma City, OK
(405) 773-8900
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Phoenix Healthcare
Operator or chain grouping
Approved since
2001-06-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
1.00
Licensed practical nurse staffing
Aide hours / resident day
3.34
Nurse aide staffing
Weekend hours
4.54
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.9
0.1 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
90.3%
6.3 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.6%
4 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
4.5%
0.8 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
3.3%
1.4 pts worse
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.7% |
3.6%
2.1 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.9% |
25.3%
15.4 pts better
|
19.6%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
18.6%
6.9 pts worse
|
16.7%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
15.5%
6.3 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
14.1%
1.3 pts worse
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.1%
1.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.8%
0.8 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
17.8%
4.5 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.1%
0.2 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
75.0%
12.6 pts better
|
81.7%
5.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.2% |
17.1%
9.1 pts worse
|
12.0%
14.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.6% |
74.0%
26.4 pts worse
|
79.7%
32.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
27.0%
5 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-06-08 · Fire 2022-06-08
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-21
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 2024-12-19
E · Potential for more than minimal harm
2024-11-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-19
F · Potential for more than minimal harm
2023-09-28
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 2024-03-20
F · Potential for more than minimal harm
2023-09-28
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-09-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-09-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-09-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-17
E · Potential for more than minimal harm
2023-09-28
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-04-17
E · Potential for more than minimal harm
2023-09-28
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 2024-04-17
E · Potential for more than minimal harm
2023-09-28
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 2024-03-20
E · Potential for more than minimal harm
2022-06-08
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 2022-07-07
E · Potential for more than minimal harm
2022-06-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-06-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-07
Inspection history
Recent health citations
G · Actual harm
2024-12-18
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 2025-01-03
D · Potential for more than minimal harm
2024-12-18
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 2025-01-03
E · Potential for more than minimal harm
2024-11-21
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 2024-12-19
E · Potential for more than minimal harm
2024-11-21
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 2024-12-19
E · Potential for more than minimal harm
2024-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-11-21
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 2024-12-19
E · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-11-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
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 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
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 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
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 2024-12-19
J · Immediate jeopardy
2024-10-11
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 2024-11-16
E · Potential for more than minimal harm
2024-10-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-11
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 2024-11-04
E · Potential for more than minimal harm
2024-08-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-12
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-09-18
E · Potential for more than minimal harm
2023-09-28
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 2023-11-07
D · Potential for more than minimal harm
2023-09-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-09-28
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 2023-11-07
E · Potential for more than minimal harm
2023-04-11
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 2023-05-25
E · Potential for more than minimal harm
2023-04-11
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 2023-05-25
E · Potential for more than minimal harm
2023-04-11
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-05-25
E · Potential for more than minimal harm
2022-06-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-06-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-06-08
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 2022-07-07
E · Potential for more than minimal harm
2022-06-08
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 2022-07-07
D · Potential for more than minimal harm
2022-06-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-07
Penalties and ownership
What sits behind the stars
$11,052
2024-11-21
Fine
Fine · fine $11,052
Fine
$8,021
2024-10-11
Fine
Fine · fine $8,021
Fine
$0
2024-10-11
Payment Denial
Payment Denial · denial start 2024-11-02 · 14 days
14 day denial
Ownership
Cain, Larry
5% Or Greater Direct Ownership Interest · Individual
Floyd, Shanna
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Hermance, Terry
Operational/Managerial Control · Individual
Jay, Judy
Operational/Managerial Control · Individual
Moxley, Heather
Operational/Managerial Control · Individual
Phoenix Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Phoenix Healthcare LLC
Operational/Managerial Control · Organization
Phoenix Rehab LLC
Operational/Managerial Control · Organization
Young, Cathy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St. Ann's Skilled Nursing And Therapy
Oklahoma City, OK
4-star overall rating with 4-star inspections with 8 recent health deficiencies
#2
The Health Center At Concordia
Oklahoma City, OK
5-star overall rating with 4-star inspections with $25,407 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Warr Acres Nursing Center
Oklahoma City, OK
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out