Cycle 1
Health 2024-10-24 · Fire 2024-10-24
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Tulsa, OK
Ambassador Manor Nursing Center
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1340 East 61St Street, Tulsa, OK
(918) 743-8978
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
171
Certified beds
Average residents
129
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
1994-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 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
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.66
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.43
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
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.58
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,047
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.70
Baseline 22.15% · Performance 20.00% · Measure score 3.70 · Achievement 3.09 · Improvement 3.70
Healthcare-associated infections
2.41
Baseline 7.69% · Performance 7.12% · Measure score 2.41 · Achievement 2.41 · Improvement 1.62
Total nurse turnover
3.83
Baseline 57.00% · Performance 48.04% · Measure score 3.83 · Achievement 3.83 · Improvement 2.29
Adjusted total nurse staffing
3.74
Baseline 4.11 hours · Performance 4.14 hours · Measure score 3.74 · Achievement 3.74 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.01% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 14.81% · Lower 95% interval 7.69% |
| Discharge to community | 42.67% |
50.57%
7.9 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 25.93% · Lower 95% interval 26.93% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 10 · Denominator 23 |
| Discharge mobility score | 21.74% |
50.94%
29.2 pts worse
|
Numerator 5 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 17.95% |
2.29%
15.7 pts worse
|
Numerator 7 · Denominator 39 · Adjusted rate 15.02% |
| Healthcare-associated infections requiring hospitalization | 7.11% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0.84% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 119 |
| Staff flu vaccination coverage | 7.55% |
42%
34.5 pts worse
|
Numerator 24 · Denominator 318 |
| Discharge function score | 39.13% |
56.45%
17.3 pts worse
|
Numerator 9 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.62% |
25.2%
9.4 pts better
|
Numerator 9 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.3
0.4 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.9
0.6 pts better
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.5 · 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 | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
4.5%
2.2 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.0% · Q3 5.5% · Q4 8.7% · 4Q avg 6.7% · 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 | 3.8% |
3.6%
0.2 pts worse
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.4% · Q3 3.8% · Q4 5.4% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
25.3%
9.1 pts better
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 14.3% · Q3 14.8% · Q4 20.4% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
18.6%
4.5 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 11.3% · Q3 11.3% · Q4 20.3% · 4Q avg 14.1% · 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 | 4.3% |
15.5%
11.2 pts better
|
16.3%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.1% · Q3 2.4% · Q4 4.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
14.1%
10.6 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.7% · Q3 2.5% · Q4 1.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.8%
1.3 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.6% · Q3 0.9% · Q4 0.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.5% |
17.8%
9.3 pts better
|
19.8%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.9% · Q3 6.4% · Q4 7.0% · 4Q avg 8.5% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.1%
1.6 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 8.6% · Q3 2.8% · Q4 8.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
75.0%
24.1 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.6% |
17.1%
7.5 pts worse
|
12.0%
12.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 27.5% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.9%
1.2 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
74.0%
19.4 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
27.0%
0.4 pts better
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 27.5% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-11-18 · Fire 2021-11-18
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-24
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-09-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-08
E · Potential for more than minimal harm
2023-09-22
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 2024-04-08
E · Potential for more than minimal harm
2023-09-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-08
F · Potential for more than minimal harm
2021-11-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
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 2021-12-28
E · Potential for more than minimal harm
2021-11-18
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 2021-12-28
E · Potential for more than minimal harm
2021-11-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-28
Inspection history
Recent health citations
K · Immediate jeopardy
2025-07-11
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 2025-07-17
E · Potential for more than minimal harm
2025-07-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-07-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-23
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-23
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 2025-07-01
D · Potential for more than minimal harm
2025-06-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-23
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 2025-07-01
D · Potential for more than minimal harm
2024-10-24
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
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 2024-11-15
D · Potential for more than minimal harm
2024-08-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-06
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 2024-02-29
D · Potential for more than minimal harm
2024-02-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-29
E · Potential for more than minimal harm
2023-09-22
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-22
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-06-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-04-07
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 2023-05-05
E · Potential for more than minimal harm
2021-11-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-12-28
E · Potential for more than minimal harm
2021-11-18
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 2021-12-28
E · Potential for more than minimal harm
2021-11-18
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 2021-12-28
Penalties and ownership
What sits behind the stars
Ownership
Bridges Employee Stock Ownership Trust
5% Or Greater Indirect Ownership Interest · Organization
Bridges Esop, Inc
5% Or Greater Direct Ownership Interest · Organization
Bridges Esop, Inc
Operational/Managerial Control · Organization
Coble, William
Operational/Managerial Control · Individual
Coble, William
Corporate Officer · Individual
Deroin, Kristy
Corporate Director · Individual
Deroin, Kristy
Contracted Managing Employee · Individual
Deroin, Kristy
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Villages At Southern Hills
Tulsa, OK
5-star overall rating with 5-star inspections
#2
Colonial Manor Nursing Home
Tulsa, OK
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Zarrow Pointe
Tulsa, OK
4-star overall rating with 3-star inspections with $8,278 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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