Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COLONIAL MANOR II
HOLLIS, OK · 92 certified beds · Last Life Safety survey June 1, 2024
CMS Certification Number 37E109 · first certified July 1978
Ownership
Independently operated (no chain recorded by CMS) · Government - County
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OK
11 citations — more than 70% of the 283 certified nursing homes in OK. Compared within OK rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (July 2025 to October 2025), and past the point by which nine in ten OK facilities have been surveyed. This facility’s last Life Safety survey was June 2024. Facilities in OK are typically surveyed 14–16 months after the last one (median 15), measured over 277 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in OK, and nationally. Surveyors differ markedly between states, so the OK figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in OK | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 22, 2022 | 8 |
| April 17, 2023 | 1 |
| June 1, 2024 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-06-01 |
| K-0222 | 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. | 1 | 2023-04-17 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-06-01 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2022-04-22 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2022-04-22 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2022-04-22 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2022-04-22 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2022-04-22 |
What the citations cover
- Smoke Deficiencies 5
- Miscellaneous Deficiencies 3
- Egress Deficiencies 2
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 1, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 18, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 13, 2024) |
April 17, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (May 18, 2023) |
April 22, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 25, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 18, 2022) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has plan of correction (July 29, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 11, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 7, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 2, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 29, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.