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
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 2 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
0.39
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.77
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
3.57
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.26
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,033
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
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
Baseline 63.16% · Performance 63.04% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.65
Baseline 4.42 hours · Performance 4.12 hours · Measure score 3.65 · Achievement 3.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 16.28% · Lower 95% interval 7.27% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 1 · Denominator 36 |
| Discharge self-care score | 48% |
53.69%
5.7 pts worse
|
Numerator 12 · Denominator 25 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 12 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 2.42% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.67% |
8.2%
6.5 pts worse
|
Numerator 1 · Denominator 60 |
| Staff flu vaccination coverage | 19.38% |
42%
22.6 pts worse
|
Numerator 25 · Denominator 129 |
| Discharge function score | 36% |
56.45%
20.5 pts worse
|
Numerator 9 · Denominator 25 |
| 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 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 35% |
25.2%
9.8 pts better
|
Numerator 7 · Denominator 20 |
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 · Adjusted 2.2 · Observed 2.4 · Expected 2.1 · Used in QM five-star |
| 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 · Adjusted 1.9 · Observed 2.1 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 92.3% · Q4 98.1% · 4Q avg 97.5% |
| 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 · 4Q avg 96.0% |
| 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 · Q1 3.9% · Q2 2.1% · Q3 0.0% · Q4 1.9% · 4Q avg 2.0% · 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 | 2.4% |
3.6%
1.2 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 2.4% |
| 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 · Q1 28.9% · Q2 23.8% · Q3 22.7% · Q4 19.6% · 4Q avg 23.7% |
| 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 · Q1 14.3% · Q2 9.4% · Q3 8.8% · Q4 6.5% · 4Q avg 9.8% · 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 | 17.7% |
15.5%
2.2 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% · Used in QM five-star |
| 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 · Q1 2.3% · Q2 22.5% · Q3 26.8% · Q4 20.9% · 4Q avg 18.0% · Used in QM five-star |
| 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 · Q1 1.7% · Q2 2.3% · Q3 0.0% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star |
| 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 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q1 2.0% · Q2 7.0% · Q3 19.7% · Q4 21.9% · 4Q avg 12.6% |
| 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 · Q1 4.4% · Q2 5.4% · Q3 6.2% · Q4 7.2% · 4Q avg 5.8% · Used in QM five-star |
| 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 · Q2 70.4% · Q3 70.0% · 4Q avg 75.3% |
| 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 · Adjusted 5.0% · Observed 5.9% · Expected 13.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 77.8% |
| 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 · Adjusted 13.6% · Observed 14.7% · Expected 25.8% · Used in QM five-star |
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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