Cycle 1
Health 2025-02-06 · Fire 2025-02-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Chickasha, OK
Cottonwood Creek Skilled Nursing & Therapy
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2300 Iowa Avenue, Chickasha, OK
(405) 224-6456
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
1993-11-01
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
0.21
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.32
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
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,621
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.62
Baseline 18.88% · Performance 20.22% · Measure score 2.62 · Achievement 2.62 · Improvement 0
Healthcare-associated infections
1.67
Baseline 7.38% · Performance 7.33% · Measure score 1.67 · Achievement 1.67 · Improvement 0
Total nurse turnover
4.85
Baseline 48.48% · Performance 43.84% · Measure score 4.85 · Achievement 4.85 · Improvement 1.47
Adjusted total nurse staffing
2.54
Baseline 3.79 hours · Performance 3.8 hours · Measure score 2.54 · Achievement 2.54 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 180 · Observed rate 10.56% · Lower 95% interval 8.19% |
| Discharge to community | 55.41% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 53.68% · Lower 95% interval 47.67% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 94 · Denominator 94 |
| Falls with major injury | 1.06% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 94 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 36 · Denominator 66 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 18 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 94 · Adjusted rate 2.08% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 6.67% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 2.5% |
8.2%
5.7 pts worse
|
Numerator 2 · Denominator 80 |
| Staff flu vaccination coverage | 21.51% |
42%
20.5 pts worse
|
Numerator 60 · Denominator 279 |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 34 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 58 · Denominator 58 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.43% |
25.2%
5.2 pts better
|
Numerator 14 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.3
0.7 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 4.1 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.9 |
2.9
3 pts worse
|
1.8
4.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.9 · Observed 7.2 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.3%
9.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 9.3% |
4.5%
4.8 pts worse
|
3.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 8.3% · Q3 8.9% · Q4 8.5% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
3.3%
0.8 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.1% · Q3 4.1% · Q4 2.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
3.6%
0.5 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.1% · Q3 2.2% · Q4 4.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.0% |
25.3%
1.7 pts worse
|
19.6%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 30.0% · Q3 17.8% · Q4 25.5% · 4Q avg 27.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
18.6%
9.8 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 9.1% · Q3 6.5% · Q4 5.7% · 4Q avg 8.8% · 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 | 19.2% |
15.5%
3.7 pts worse
|
16.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
14.1%
0.2 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 15.9% · Q3 11.9% · Q4 2.1% · 4Q avg 13.9% · 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 | 5.2% |
2.8%
2.4 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 1.7% · Q3 8.9% · Q4 0.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
17.8%
0.5 pts worse
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 19.3% · Q3 14.7% · Q4 20.2% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.1%
0.9 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.0% · Q3 3.7% · Q4 4.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
75.0%
23 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 96.9% · Q3 98.0% · Q4 98.9% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.7% |
17.1%
6.6 pts worse
|
12.0%
11.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 26.0% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.9%
0.3 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.6% · Q4 1.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
74.0%
23 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
27.0%
0.5 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 28.6% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-19
F · Potential for more than minimal harm
2022-11-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-20
F · Potential for more than minimal harm
2022-11-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
C · Minimal harm
2022-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-02-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-02-06
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 2025-02-19
D · Potential for more than minimal harm
2025-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-02-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-19
E · Potential for more than minimal harm
2023-12-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
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 2024-01-16
D · Potential for more than minimal harm
2023-12-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-14
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 2024-01-16
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
E · Potential for more than minimal harm
2022-11-18
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-18
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 2022-12-20
D · Potential for more than minimal harm
2022-11-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-20
D · Potential for more than minimal harm
2022-11-18
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 2022-12-20
D · Potential for more than minimal harm
2022-11-18
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 2022-12-20
D · Potential for more than minimal harm
2022-11-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-20
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
Glenhaven Retirement Village
Chickasha, OK
3-star overall rating with 3-star inspections with $14,433 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Shanoan Springs Nursing And Rehabilitation
Chickasha, OK
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Chickasha Nursing Center, Inc
Chickasha, OK
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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