Cycle 1
Health 2024-07-03 · Fire 2024-07-03
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ponca City, OK
Bradbury Commons
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
1601 Academy Road, Ponca City, OK
(580) 370-7132
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Via Christi Villages
Operator or chain grouping
Approved since
2008-03-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 5 overall / 5 health / 4 staffing / 4 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
0.34
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.22
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
0.07
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,448
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.09% · Performance 22.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.11
Baseline 7.55% · Performance 6.91% · Measure score 3.11 · Achievement 3.11 · Improvement 2.02
Total nurse turnover
1.65
Baseline 61.19% · Performance 56.92% · Measure score 1.65 · Achievement 1.65 · Improvement 0.68
Adjusted total nurse staffing
3.38
Baseline 4.08 hours · Performance 4.04 hours · Measure score 3.38 · Achievement 3.38 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 10.45% · Lower 95% interval 8.65% |
| Discharge to community | 56.66% |
50.57%
6.1 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 57.6% · Lower 95% interval 49.46% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.37% |
95.27%
7.9 pts worse
|
Numerator 83 · Denominator 95 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 95 |
| Discharge self-care score | 64.62% |
53.69%
10.9 pts better
|
Numerator 42 · Denominator 65 |
| Discharge mobility score | 73.85% |
50.94%
22.9 pts better
|
Numerator 48 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 3.16% |
2.29%
0.9 pts worse
|
Numerator 3 · Denominator 95 · Adjusted rate 4.4% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 4.82% · Lower 95% interval 3.87% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 80 |
| Staff flu vaccination coverage | 86.54% |
42%
44.5 pts better
|
Numerator 90 · Denominator 104 |
| Discharge function score | 75.38% |
56.45%
18.9 pts better
|
Numerator 49 · Denominator 65 |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 42 · Denominator 46 |
| Transfer of health information to patient | 97.22% |
96.28%
0.9 pts better
|
Numerator 35 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 29.27% |
25.2%
4.1 pts better
|
Numerator 12 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.9
0.2 pts better
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 1.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
90.3%
7.5 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 97.9% · Q3 100.0% · Q4 97.8% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
94.6%
1.3 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
4.5%
0.6 pts better
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.1% · Q3 4.3% · Q4 4.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
3.3%
2.9 pts worse
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.4% · Q3 8.9% · Q4 0.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
3.6%
3.4 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 3.0% · Q3 12.9% · Q4 3.0% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
25.3%
13 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 9.1% · Q3 9.4% · Q4 9.1% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
18.6%
8.3 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 16.1% · Q3 11.1% · Q4 3.3% · 4Q avg 10.3% · 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 | 19.8% |
15.5%
4.3 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 32.2% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.9% |
14.1%
15.8 pts worse
|
14.9%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 36.4% · Q3 35.5% · Q4 31.2% · 4Q avg 29.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.1%
1.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.8%
0.6 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 6.7% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
17.8%
11.6 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 27.6% · Q3 31.5% · Q4 34.5% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.1%
0.9 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 13.2% · Q3 4.1% · Q4 3.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.0% |
75.0%
8 pts worse
|
81.7%
14.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.1% · Q2 67.7% · Q3 59.6% · Q4 70.8% · 4Q avg 67.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.9% |
17.1%
7.8 pts worse
|
12.0%
12.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 22.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.9%
0.2 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 4.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.1% |
74.0%
3.1 pts better
|
79.7%
2.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.1% |
27.0%
6.1 pts worse
|
23.9%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.1% · Observed 26.2% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-07-11 · Fire 2019-07-11
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-03
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 2024-08-02
E · Potential for more than minimal harm
2024-07-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-02
C · Minimal harm
2024-07-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-02
F · Potential for more than minimal harm
2023-05-25
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 2023-08-31
F · Potential for more than minimal harm
2023-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-05-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-05-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-05-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-31
E · Potential for more than minimal harm
2019-07-11
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 2019-07-15
E · Potential for more than minimal harm
2019-07-11
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 2019-07-15
E · Potential for more than minimal harm
2019-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-15
Inspection history
Recent health citations
J · Immediate jeopardy
2023-03-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-03-21
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 2023-04-28
D · Potential for more than minimal harm
2023-03-21
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 2023-04-28
E · Potential for more than minimal harm
2023-03-03
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 2023-04-10
D · Potential for more than minimal harm
2023-03-03
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 2023-01-10
G · Actual harm
2019-07-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-08-13
E · Potential for more than minimal harm
2019-07-11
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 2019-08-13
E · Potential for more than minimal harm
2019-07-11
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 2019-08-13
E · Potential for more than minimal harm
2019-07-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-08-13
D · Potential for more than minimal harm
2019-07-11
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-08-13
D · Potential for more than minimal harm
2019-07-11
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 2019-08-13
D · Potential for more than minimal harm
2019-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-13
Penalties and ownership
What sits behind the stars
Ownership
Via Christi Villages Inc
5% Or Greater Direct Ownership Interest · Organization
Ascension Health Senior Care
Operational/Managerial Control · Organization
Breedlove, Ryan
Corporate Director · Individual
Musgrave, Lisa
Corporate Director · Individual
Shadbolt, Erin
Corporate Director · Individual
Smoot, Kenneth
Corporate Director · Individual
Spillars, Rodger
Operational/Managerial Control · Individual
Young, Adam
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Shawn Manor Nursing Home
Ponca City, OK
5-star overall rating with 5-star inspections with 3 recent health deficiencies
#2
Ponca City Nursing & Rehabilitation Center
Ponca City, OK
5-star overall rating with 5-star inspections with 3 recent health deficiencies
#3
Hillcrest Manor Nursing Center
Blackwell, OK
1-star overall rating with 2-star inspections with $46,898 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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