Moore, OK
1-star overall rating with 1-star inspections with abuse icon flag with $30,137 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2120 North Broadway, Moore, OK
(405) 794-2428
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
154
Certified beds
Average residents
121
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ihs Management Consultants
Operator or chain grouping
Approved since
1997-11-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 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
RN hours / resident day
0.19
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
0.87
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
4.27
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Program rank
13,361
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 66.67% · Performance 65.91% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.24
Baseline 3.44 hours · Performance 3.43 hours · Measure score 1.24 · Achievement 1.24 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · 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 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.04% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 98 |
| Staff flu vaccination coverage | 8.74% |
42%
33.3 pts worse
|
Numerator 9 · Denominator 103 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
| 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 1.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.9
0.8 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.6 · 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 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.5% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.6%
3.7 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
4.5%
0.5 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 7.6% · Q4 6.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
3.3%
1.8 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.1% · Q3 0.9% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
3.6%
1.2 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.9% · Q3 2.8% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
25.3%
2.1 pts better
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 20.4% · Q3 19.8% · Q4 22.9% · 4Q avg 23.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.0% |
18.6%
15.4 pts worse
|
16.7%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 30.3% · Q3 34.2% · Q4 39.1% · 4Q avg 34.0% · 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 | 9.2% |
15.5%
6.3 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 17.5% · Q3 5.1% · Q4 9.0% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.2% |
14.1%
6.9 pts better
|
14.9%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 5.1% · Q3 4.0% · Q4 12.0% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
2.1%
0.1 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 2.3% · Q4 3.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
2.8%
2.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.4% |
17.8%
3.4 pts better
|
19.8%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 17.5% · Q3 16.3% · Q4 9.2% · 4Q avg 14.4% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.1%
0.5 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.8% · Q3 5.2% · Q4 2.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
75.0%
24 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.1% |
74.0%
14.9 pts worse
|
79.7%
20.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.1% |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-30
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
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-05
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 2024-03-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-15
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-15
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-15
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-24
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-11-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-11-24
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-05
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-05
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-05
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 2025-09-05
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 2025-05-30
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-05-30
Health
Post nurse staffing information every day.
Corrected 2025-05-30
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-11
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-11
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-29
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-03-05
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-23
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-23
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-23
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-23
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 2024-02-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-23
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-02-23
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 2024-02-23
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
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 2023-02-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-15
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-02-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-15
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-15
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 2023-02-15
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-15
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-02-15
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-02-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-15
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-15
Penalties and ownership
Payment Denial · denial start 2025-11-07 · 21 days
21 day denial
Fine · fine $30,137
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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