Cycle 1
Health 2025-09-17 · Fire 2025-09-17
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Oklahoma City, OK
Brookwood Skilled Nursing and Therapy
1-star overall rating with 1-star inspections with $45,353 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
940 Southwest 84th Street, Oklahoma City, OK
(405) 636-0626
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
137
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
1990-05-30
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
0.47
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.27
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
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,939
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.41% · Performance 21.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.33% · Performance 8.71% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.60
Baseline 57.69% · Performance 48.96% · Measure score 3.60 · Achievement 3.60 · Improvement 2.16
Adjusted total nurse staffing
2.24
Baseline 4.02 hours · Performance 3.72 hours · Measure score 2.24 · Achievement 2.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.39% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 278 · Observed rate 12.95% · Lower 95% interval 9.05% |
| Discharge to community | 52.57% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 240 · Observed rate 48.33% · Lower 95% interval 47.21% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 195 · Denominator 195 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 195 |
| Discharge self-care score | 51.69% |
53.69%
2 pts worse
|
Numerator 61 · Denominator 118 |
| Discharge mobility score | 35.59% |
50.94%
15.3 pts worse
|
Numerator 42 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 3.59% |
2.29%
1.3 pts worse
|
Numerator 7 · Denominator 195 · Adjusted rate 3.63% |
| Healthcare-associated infections requiring hospitalization | 8.71% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 9.94% · Lower 95% interval 5.91% |
| Staff COVID-19 vaccination coverage | 2.36% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 127 |
| Staff flu vaccination coverage | 14.63% |
42%
27.4 pts worse
|
Numerator 66 · Denominator 451 |
| Discharge function score | 43.22% |
56.45%
13.2 pts worse
|
Numerator 51 · Denominator 118 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 64 · Denominator 64 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 104 · Denominator 104 |
| Resident COVID-19 vaccinations up to date | 17.17% |
25.2%
8 pts worse
|
Numerator 17 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.9
0.6 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
90.3%
8.2 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.1% · Q4 97.8% · 4Q avg 98.5% |
| 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 | 1.8% |
4.5%
2.7 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 1.3% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
3.3%
2.3 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.9% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
3.6%
0.2 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.6% · Q3 3.2% · Q4 4.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
25.3%
9.7 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 16.4% · Q3 15.6% · Q4 13.3% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
18.6%
4.9 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 10.9% · Q3 11.5% · Q4 14.5% · 4Q avg 13.7% · 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 | 8.3% |
15.5%
7.2 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q3 9.4% · Q4 3.6% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
14.1%
7.8 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 10.8% · Q3 7.9% · Q4 2.7% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
2.1%
0.7 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 0.0% · Q4 1.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.8%
1 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.6% · Q3 1.3% · Q4 1.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
17.8%
0.2 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 24.7% · Q3 15.9% · Q4 10.3% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 12.3% |
5.1%
7.2 pts worse
|
5.1%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 14.1% · Q3 12.3% · Q4 13.1% · 4Q avg 12.3% · 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 98.5% · Q2 98.9% · Q3 99.6% · Q4 99.5% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
17.1%
0.2 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 17.6% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.9%
0.4 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 0.0% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
74.0%
22.9 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
27.0%
2.5 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 24.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-07 · Fire 2024-05-07
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-03-27 · Fire 2023-03-27
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-02
C · Minimal harm
2025-09-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-02
F · Potential for more than minimal harm
2024-05-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-02
E · Potential for more than minimal harm
2023-03-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-03-27
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 2023-06-06
E · Potential for more than minimal harm
2023-03-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-03-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-25
G · Actual harm
2025-09-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-27
F · Potential for more than minimal harm
2025-09-17
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-09-17
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 2025-09-27
D · Potential for more than minimal harm
2025-09-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-27
J · Immediate jeopardy
2025-01-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-11
J · Immediate jeopardy
2025-01-07
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-02-11
E · Potential for more than minimal harm
2025-01-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-11-13
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 2024-12-17
D · Potential for more than minimal harm
2024-11-13
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 2024-12-17
E · Potential for more than minimal harm
2024-05-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-07
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 2024-06-19
E · Potential for more than minimal harm
2024-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-07
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 2024-06-19
D · Potential for more than minimal harm
2024-05-07
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 2024-06-19
D · Potential for more than minimal harm
2024-05-07
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-07
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 2024-06-19
D · Potential for more than minimal harm
2024-05-07
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 2024-06-19
E · Potential for more than minimal harm
2023-07-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-03-27
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 2023-06-06
E · Potential for more than minimal harm
2023-03-27
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 2023-06-06
D · Potential for more than minimal harm
2023-03-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-03-27
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 2023-06-06
D · Potential for more than minimal harm
2023-03-27
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 2023-06-06
D · Potential for more than minimal harm
2023-03-27
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-06-06
Penalties and ownership
What sits behind the stars
$17,215
2025-09-17
Fine
Fine · fine $17,215
Fine
$0
2025-09-17
Payment Denial
Payment Denial · denial start 2025-12-17 · 5 days
5 day denial
$14,069
2025-01-07
Fine
Fine · fine $14,069
Fine
$14,069
2025-01-07
Fine
Fine · fine $14,069
Fine
Ownership
Bridges Employee Stock Ownership Trust
5% Or Greater Indirect Ownership Interest · Organization
Bridges Esop, Inc
5% Or Greater Direct Ownership Interest · Organization
Amity Care, LLC
Operational/Managerial Control · Organization
Coble, William
Corporate Director · Individual
Deroin, Kristy
Corporate Director · Individual
Long, Dennis
Operational/Managerial Control · Individual
Taylor, Londell
Operational/Managerial Control · Individual
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#3
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