Cycle 1
Health 2025-02-06 · Fire 2025-02-06
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Tulsa, OK
Colonial Manor Nursing Home
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1815 East Skelly Drive, Tulsa, OK
(918) 743-7838
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Diakonos Group
Operator or chain grouping
Approved since
2004-04-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing
LPN hours / resident day
0.77
Licensed practical nurse staffing
Aide hours / resident day
2.41
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.9
1 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
90.3%
7.2 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
94.6%
1.4 pts better
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
4.5%
2.5 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 2.4% |
3.6%
1.2 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.7% |
25.3%
1.6 pts better
|
19.6%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
18.6%
8.8 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.7% |
15.5%
2.2 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
14.1%
3.9 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.1%
0.9 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.8%
1.8 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
17.8%
5.2 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.1%
0.7 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.3% |
75.0%
0.3 pts better
|
81.7%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
17.1%
12.1 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.8% |
74.0%
3.8 pts better
|
79.7%
1.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
27.0%
13.4 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-08 · Fire 2023-02-08
5 health deficiencies
Top issue: Environmental (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-06
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 2025-03-15
C · Minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-15
E · Potential for more than minimal harm
2023-12-01
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 2024-05-06
E · Potential for more than minimal harm
2023-12-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-06
F · Potential for more than minimal harm
2023-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-08
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 2023-05-05
E · Potential for more than minimal harm
2023-02-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-05
E · Potential for more than minimal harm
2023-02-08
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-08
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-05
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-21
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-21
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 2025-08-22
D · Potential for more than minimal harm
2025-07-21
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 2025-08-22
D · Potential for more than minimal harm
2025-07-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-02-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-10-25
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 2024-10-22
E · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-03-15
E · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-01
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 2024-01-30
D · Potential for more than minimal harm
2023-12-01
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-02-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-08
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 2023-04-28
D · Potential for more than minimal harm
2023-02-08
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-05
Penalties and ownership
What sits behind the stars
$0
2025-07-21
Payment Denial
Payment Denial · denial start 2025-08-28 · 7 days
7 day denial
Ownership
Diakonos Group, LLC
5% Or Greater Direct Ownership Interest · Organization
Pilgrim, Scott
5% Or Greater Indirect Ownership Interest · Individual
Bush, William
Operational/Managerial Control · Individual
Diakonos Group, LLC
Operational/Managerial Control · Organization
Mullins, Terri
Operational/Managerial Control · Individual
Pilgrim, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Villages At Southern Hills
Tulsa, OK
5-star overall rating with 5-star inspections
#2
Ambassador Manor Nursing Center
Tulsa, OK
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Zarrow Pointe
Tulsa, OK
4-star overall rating with 3-star inspections with $8,278 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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