Cycle 1
Health 2024-11-12 · Fire 2024-11-12
10 health deficiencies
Top issue: Administration (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Oklahoma City, OK
Capitol Hill Skilled Nursing And Therapy
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2400 Southwest 55th Street, Oklahoma City, OK
(405) 681-5381
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
120
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
1994-02-01
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
0.31
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.93
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
3.54
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.18
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
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,894
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.02
Baseline 23.67% · Performance 20.67% · Measure score 4.02 · Achievement 1.65 · Improvement 4.02
Healthcare-associated infections
3.71
Baseline 6.82% · Performance 6.73% · Measure score 3.71 · Achievement 3.71 · Improvement 0.04
Total nurse turnover
2.44
Baseline 46.30% · Performance 53.70% · Measure score 2.44 · Achievement 2.44 · Improvement 0
Adjusted total nurse staffing
2.39
Baseline 4.35 hours · Performance 3.76 hours · Measure score 2.39 · Achievement 2.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 11.11% · Lower 95% interval 6.57% |
| Discharge to community | 48.7% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 42.11% · Lower 95% interval 35.98% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.87% |
95.27%
0.4 pts worse
|
Numerator 37 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 12.82% |
2.29%
10.5 pts worse
|
Numerator 5 · Denominator 39 · Adjusted rate 11.49% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 1.49% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 67 |
| Staff flu vaccination coverage | 13.1% |
42%
28.9 pts worse
|
Numerator 33 · Denominator 252 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 3 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.9
0.8 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
90.3%
3.5 pts better
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 96.8% · Q3 96.4% · Q4 91.2% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.6%
4 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
4.5%
3.7 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 | 4.4% |
3.6%
0.8 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.3% · Q3 3.8% · Q4 3.7% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
25.3%
About the same
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 25.9% · Q3 22.6% · Q4 29.6% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
18.6%
6.7 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 12.5% · Q3 11.1% · Q4 17.1% · 4Q avg 11.9% · 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 | 13.6% |
15.5%
1.9 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 27.7% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
14.1%
5.8 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 12.7% · Q3 4.0% · Q4 0.0% · 4Q avg 8.3% · 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 | 1.3% |
2.8%
1.5 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.5% |
17.8%
3.3 pts better
|
19.8%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 17.5% · Q3 12.3% · Q4 18.8% · 4Q avg 14.5% |
| Percentage of long-stay residents with pressure ulcers | 10.1% |
5.1%
5 pts worse
|
5.1%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 8.5% · Q3 9.4% · Q4 10.7% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.3% |
75.0%
2.7 pts worse
|
81.7%
9.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 65.1% · Q3 66.0% · Q4 82.6% · 4Q avg 72.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.4% |
17.1%
1.3 pts worse
|
12.0%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 18.8% · Expected 11.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.7% |
74.0%
7.3 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.6% |
27.0%
8.6 pts worse
|
23.9%
11.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.6% · Observed 34.4% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-29 · Fire 2023-08-29
3 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-09-03 · Fire 2021-09-03
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-12
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 2024-12-10
E · Potential for more than minimal harm
2024-11-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-12
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 2024-12-10
F · Potential for more than minimal harm
2023-08-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-10
E · Potential for more than minimal harm
2023-08-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-10
E · Potential for more than minimal harm
2021-09-03
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 2021-09-30
E · Potential for more than minimal harm
2021-09-03
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 2021-09-30
E · Potential for more than minimal harm
2021-09-03
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-09-30
E · Potential for more than minimal harm
2021-09-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
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 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
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 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-12
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-12-10
D · Potential for more than minimal harm
2023-08-29
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 2023-09-27
D · Potential for more than minimal harm
2023-08-29
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 2023-09-27
D · Potential for more than minimal harm
2023-08-29
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2023-09-27
E · Potential for more than minimal harm
2021-09-03
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-09-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-09-30
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
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
South Pointe Rehabilitation and Care Center
Oklahoma City, OK
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $202,060 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Emerald Care Center Southwest LLC
Oklahoma City, OK
1-star overall rating with 1-star inspections with $8,278 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Brookwood Skilled Nursing and Therapy
Oklahoma City, OK
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
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