Cycle 1
Health 2024-06-05 · Fire 2024-06-05
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Oklahoma City, OK
Bellevue Health & Rehabilitation Center
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
6500 North Portland Avenue, Oklahoma City, OK
(405) 767-6500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
128
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-08-28
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
0.35
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
4.20
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,852
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9914
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.28
Baseline 21.74% · Performance 20.43% · Measure score 2.28 · Achievement 2.15 · Improvement 2.28
Healthcare-associated infections
1.87
Baseline 6.06% · Performance 7.28% · Measure score 1.87 · Achievement 1.87 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.36
Baseline 5.34 hours · Performance 5.17 hours · Measure score 7.36 · Achievement 7.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 657 · Observed rate 9.89% · Lower 95% interval 8.16% |
| Discharge to community | 62.79% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 589 · Observed rate 58.4% · Lower 95% interval 59.51% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.58% |
95.27%
0.7 pts worse
|
Numerator 489 · Denominator 517 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 4 · Denominator 517 |
| Discharge self-care score | 39.13% |
53.69%
14.6 pts worse
|
Numerator 135 · Denominator 345 |
| Discharge mobility score | 30.43% |
50.94%
20.5 pts worse
|
Numerator 105 · Denominator 345 |
| Pressure ulcers or injuries, new or worsened | 3.48% |
2.29%
1.2 pts worse
|
Numerator 18 · Denominator 517 · Adjusted rate 3.37% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 405 · Observed rate 6.91% · Lower 95% interval 5.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 168 |
| Staff flu vaccination coverage | 5.16% |
42%
36.8 pts worse
|
Numerator 16 · Denominator 310 |
| Discharge function score | 42.9% |
56.45%
13.6 pts worse
|
Numerator 148 · Denominator 345 |
| Transfer of health information to provider | 95.39% |
95.95%
0.6 pts worse
|
Numerator 145 · Denominator 152 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 286 · Denominator 286 |
| Resident COVID-19 vaccinations up to date | 48.49% |
25.2%
23.3 pts better
|
Numerator 145 · Denominator 299 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.9
0.4 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.0 · 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 | 97.6% |
94.6%
3 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
4.5%
0.1 pts better
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.3% · Q3 5.3% · Q4 1.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
3.3%
3.4 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.1% · Q3 7.4% · Q4 7.6% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
3.6%
3.8 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 15.8% · Q3 5.3% · Q4 3.4% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.0% |
25.3%
0.3 pts better
|
19.6%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 28.3% · Q3 23.0% · Q4 24.2% · 4Q avg 25.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
18.6%
15.5 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 1.9% · Q4 7.3% · 4Q avg 3.1% · 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 | 8.1% |
15.5%
7.4 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.1% · Q3 11.4% · Q4 4.3% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.9% |
14.1%
3.8 pts worse
|
14.9%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 16.1% · Q3 17.5% · Q4 22.8% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
2.1%
1.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
2.8%
1.1 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.8% · Q3 5.6% · Q4 2.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
17.8%
1.7 pts worse
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 22.2% · Q3 16.8% · Q4 13.2% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.1%
3.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 4.4% · Q4 2.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
75.0%
21.7 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 95.9% · Q3 97.3% · Q4 97.3% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
17.1%
4.2 pts better
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 13.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.9%
1.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
74.0%
16.2 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
27.0%
2.4 pts better
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 25.3% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-28 · Fire 2023-04-28
5 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-02-22 · Fire 2022-02-22
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-06-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-07-03
E · Potential for more than minimal harm
2023-04-28
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-04-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-04-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-06-29
E · Potential for more than minimal harm
2022-02-22
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 2022-03-15
E · Potential for more than minimal harm
2022-02-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-15
E · Potential for more than minimal harm
2022-02-22
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2022-02-17
E · Potential for more than minimal harm
2022-02-22
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 2022-03-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-18
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2026-01-30
E · Potential for more than minimal harm
2025-12-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-09-11
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 2025-10-06
E · Potential for more than minimal harm
2024-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-05
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 2024-07-05
D · Potential for more than minimal harm
2024-06-05
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 2024-07-05
E · Potential for more than minimal harm
2023-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-04-28
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 2023-05-31
E · Potential for more than minimal harm
2023-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-28
F578 · Resident Rights Deficiencies
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 2023-05-31
D · Potential for more than minimal harm
2023-04-28
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-05-31
E · Potential for more than minimal harm
2022-02-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-03-18
Penalties and ownership
What sits behind the stars
Ownership
Bellevue Northwest Nursing Center LLC
5% Or Greater Direct Ownership Interest · Organization
Bellevue Convalescent Hospital, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Botello, David
Operational/Managerial Control · Individual
Botello, Haley
Operational/Managerial Control · Individual
Botello, Haley
Corporate Officer · Individual
Burgess, Diane
5% Or Greater Indirect Ownership Interest · Individual
Deaver, Jeffrey
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Fuechsel, Kelley
5% Or Greater Indirect Ownership Interest · Individual
Fuechsel, Kelley
Operational/Managerial Control · Individual
Gfeller, Healther
Operational/Managerial Control · Individual
Gfeller, Healther
Corporate Officer · Individual
Hardeman, Nancy
5% Or Greater Indirect Ownership Interest · Individual
Meadows, Tamara
Operational/Managerial Control · Individual
Rangel, Oscar
Operational/Managerial Control · Individual
Robert A. Thompson 2000 Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Shirey, Brianne
Operational/Managerial Control · Individual
Stuart, Hollie
5% Or Greater Indirect Ownership Interest · Individual
Stuart, Matt
5% Or Greater Indirect Ownership Interest · Individual
Stuart, Matt
Corporate Officer · Individual
Thompson, Norman
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Tara
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Turner
5% Or Greater Indirect Ownership Interest · Individual
Waxman, Kathleen
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Ignite Medical Resort Okc, LLC
Oklahoma City, OK
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Northwest Nursing Center
Oklahoma City, OK
3-star overall rating with 3-star inspections with $10,062 in total fines with 6 recent health deficiencies
#3
The Lodge At Brookline
Oklahoma City, OK
1-star overall rating with 1-star inspections with $37,980 in total fines with 18 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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