Cycle 1
Health 2024-08-29 · Fire 2024-08-29
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Tishomingo, OK
Blue River Healthcare, Inc
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1105 East Main, Tishomingo, OK
(580) 371-2636
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elmbrook Management Company
Operator or chain grouping
Approved since
1997-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 4 health / 3 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
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,326
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
Performance 74.14% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.57
Baseline 3.48 hours · Performance 3.81 hours · Measure score 2.57 · Achievement 2.57 · Improvement 0.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.23% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 16.67% · Lower 95% interval 7.57% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 3.85% |
0.77%
3.1 pts worse
|
Numerator 1 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 11.54% |
2.29%
9.2 pts worse
|
Numerator 3 · Denominator 26 · Adjusted rate 9.98% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 65 |
| Staff flu vaccination coverage | 4.26% |
42%
37.7 pts worse
|
Numerator 4 · Denominator 94 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
90.3%
4.7 pts better
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 92.9% · Q3 100.0% · Q4 97.2% · 4Q avg 95.0% |
| 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 | 3.7% |
4.5%
0.8 pts better
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.4% · Q3 2.5% · Q4 5.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
3.3%
3.5 pts worse
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 8.3% · Q3 2.9% · Q4 3.3% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
3.6%
1 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.4% · Q3 3.6% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.1% |
25.3%
7.8 pts worse
|
19.6%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 25.8% · Q3 35.7% · Q4 48.0% · 4Q avg 33.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
18.6%
12.6 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.1% · Q3 4.5% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.6% |
0.1%
0.5 pts worse
|
0.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents whose ability to walk independently worsened | 34.6% |
15.5%
19.1 pts worse
|
16.3%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.0% |
14.1%
8.9 pts worse
|
14.9%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 28.6% · Q3 30.4% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.1%
1.5 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.8%
1.5 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
17.8%
5.9 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 15.2% · Q3 8.0% · Q4 15.1% · 4Q avg 11.9% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.1%
2.7 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 3.5% · Q4 2.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.2% |
75.0%
33.8 pts worse
|
81.7%
40.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 41.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-03-10 · Fire 2022-03-10
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-29
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-10-15
E · Potential for more than minimal harm
2023-07-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-07-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-07-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-29
F · Potential for more than minimal harm
2022-03-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-29
F · Potential for more than minimal harm
2022-03-10
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 2022-03-29
E · Potential for more than minimal harm
2022-03-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-03-29
E · Potential for more than minimal harm
2022-03-10
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 2022-03-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-08-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-29
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 2024-10-01
D · Potential for more than minimal harm
2023-08-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-08-31
E · Potential for more than minimal harm
2022-03-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-29
D · Potential for more than minimal harm
2022-03-10
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-03-29
Penalties and ownership
What sits behind the stars
Ownership
Coble, Tom
5% Or Greater Direct Ownership Interest · Individual
Blue River Healthcare Inc.
Operational/Managerial Control · Organization
Coble, Tom
Operational/Managerial Control · Individual
Coble, Tom
Corporate Officer · Individual
Dixson, James
Operational/Managerial Control · Individual
Lodes, Jason
Operational/Managerial Control · Individual
Lodes, Jason
Corporate Officer · Individual
Mcglamery, Dena
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Brookside Nursing Center
Madill, OK
1-star overall rating with 1-star inspections with abuse icon flag with $39,487 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Family Care Center Of Kingston
Kingston, OK
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The King's Daughters & Sons Nursing Home
Durant, OK
4-star overall rating with 3-star inspections with $15,249 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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