Cycle 1
Health 2025-05-22 · Fire 2025-05-22
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Duncan, OK
Wilkins Health & Rehabilitation Community
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1205 South 4th Street, Duncan, OK
(580) 252-3955
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-11-18
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
0.43
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.45
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
0.98
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.93
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
0.01
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
5.34
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,694
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.60
Baseline 18.44% · Performance 19.76% · Measure score 3.60 · Achievement 3.60 · Improvement 0
Healthcare-associated infections
0
Baseline 5.52% · Performance 7.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.98
Baseline 47.93% · Performance 51.49% · Measure score 2.98 · Achievement 2.98 · Improvement 0
Adjusted total nurse staffing
7.53
Baseline 4.54 hours · Performance 5.22 hours · Measure score 7.53 · Achievement 7.53 · Improvement 4.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.55% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 12.42% · Lower 95% interval 8.54% |
| Discharge to community | 44.08% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 38.1% · Lower 95% interval 35.05% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 94 · Denominator 94 |
| Falls with major injury | 3.19% |
0.77%
2.4 pts worse
|
Numerator 3 · Denominator 94 |
| Discharge self-care score | 46.88% |
53.69%
6.8 pts worse
|
Numerator 30 · Denominator 64 |
| Discharge mobility score | 31.25% |
50.94%
19.7 pts worse
|
Numerator 20 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 94 · Adjusted rate 2.31% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 8.79% · Lower 95% interval 4.76% |
| Staff COVID-19 vaccination coverage | 49.4% |
8.2%
41.2 pts better
|
Numerator 82 · Denominator 166 |
| Staff flu vaccination coverage | 16.25% |
42%
25.8 pts worse
|
Numerator 26 · Denominator 160 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 32 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 47 · Denominator 47 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.41% |
25.2%
4.8 pts worse
|
Numerator 10 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.9
0.3 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.8% |
90.3%
28.5 pts worse
|
93.4%
31.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 59.4% · Q2 68.9% · Q3 65.6% · Q4 53.1% · 4Q avg 61.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
94.6%
0.8 pts worse
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
4.5%
4 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 10.7% · Q3 7.3% · Q4 7.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.3%
3.3 pts better
|
11.4%
11.4 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 who lose too much weight | 4.0% |
3.6%
0.4 pts worse
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.4% · Q3 5.1% · Q4 4.9% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.2% |
25.3%
1.9 pts worse
|
19.6%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 26.6% · Q3 26.8% · Q4 27.4% · 4Q avg 27.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
18.6%
13 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 5.8% · Q4 9.8% · 4Q avg 5.6% · 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 | 26.9% |
15.5%
11.4 pts worse
|
16.3%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 30.9% · Q3 22.3% · Q4 30.3% · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.1% |
14.1%
19 pts worse
|
14.9%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 39.3% · Q3 32.9% · Q4 25.6% · 4Q avg 33.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
2.1%
1.2 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.8%
0.9 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 3.2% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
17.8%
12.2 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 33.4% · Q3 27.3% · Q4 31.1% · 4Q avg 30.0% |
| 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 1.4% · Q2 4.3% · Q3 7.3% · Q4 5.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 32.8% |
75.0%
42.2 pts worse
|
81.7%
48.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.7% · Q2 41.1% · Q3 25.0% · Q4 28.7% · 4Q avg 32.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.8% |
17.1%
3.7 pts worse
|
12.0%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 21.8% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.9%
1.5 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.3% |
74.0%
31.7 pts worse
|
79.7%
37.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
27.0%
7.2 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 20.5% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-29 · Fire 2024-01-29
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
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 2025-07-03
F · Potential for more than minimal harm
2025-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-03
E · Potential for more than minimal harm
2025-05-22
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-07-03
E · Potential for more than minimal harm
2024-01-29
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 2024-04-12
E · Potential for more than minimal harm
2024-01-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-12
F · Potential for more than minimal harm
2022-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-17
C · Minimal harm
2022-11-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-22
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-03-26
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 2025-04-11
D · Potential for more than minimal harm
2025-01-13
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 2025-01-23
D · Potential for more than minimal harm
2024-01-29
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 2024-02-13
D · Potential for more than minimal harm
2024-01-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-29
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-02-13
D · Potential for more than minimal harm
2022-11-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
Ownership
Wilkins, Tony
5% Or Greater Direct Ownership Interest · Individual
Brown, James
5% Or Greater Direct Ownership Interest · Individual
Wilkins, Tyler
5% Or Greater Direct Ownership Interest · Individual
Attaway, Kathryn
Operational/Managerial Control · Individual
Boykins, Tysheika
Operational/Managerial Control · Individual
Brown, James
Corporate Officer · Individual
Duncan, Royce
Operational/Managerial Control · Individual
Ellis, Beverly
Operational/Managerial Control · Individual
Fitzgerald, Ron
Operational/Managerial Control · Individual
Mcgouran, Francis
Operational/Managerial Control · Individual
Parker, Jessica
Operational/Managerial Control · Individual
Wilkins, Melanie
Corporate Officer · Individual
Wilkins, Tony
Corporate Officer · Individual
Wilkins, Tyler
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Elk Crossing
Duncan, OK
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Meridian Nursing Home
Comanche, OK
4-star overall rating with 5-star inspections
#3
Gregston Nursing Home, Inc.
Marlow, OK
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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