Cycle 1
Health 2024-10-03 · Fire 2024-10-03
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Oklahoma City, OK
Epworth Villa Health Services
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
14901 North Penn Avenue, Oklahoma City, OK
(405) 752-1200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-01-24
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.42
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
5.17
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
4.55
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
5.41
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,361
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0124
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.78% · Performance 23.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.51
Baseline 4.38% · Performance 5.59% · Measure score 7.51 · Achievement 7.51 · Improvement 0
Total nurse turnover
5.39
Baseline 45.05% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 1.18
Adjusted total nurse staffing
10
Baseline 5.43 hours · Performance 6.50 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 624 · Observed rate 7.85% · Lower 95% interval 8.16% |
| Discharge to community | 65.89% |
50.57%
15.3 pts better
|
Better than the National Rate · Eligible stays 594 · Observed rate 65.32% · Lower 95% interval 61.5% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 23.53% |
95.27%
71.7 pts worse
|
Numerator 84 · Denominator 357 |
| Falls with major injury | 1.4% |
0.77%
0.6 pts worse
|
Numerator 5 · Denominator 357 |
| Discharge self-care score | 53% |
53.69%
0.7 pts worse
|
Numerator 150 · Denominator 283 |
| Discharge mobility score | 26.5% |
50.94%
24.4 pts worse
|
Numerator 75 · Denominator 283 |
| Pressure ulcers or injuries, new or worsened | 0.28% |
2.29%
2 pts better
|
Numerator 1 · Denominator 357 · Adjusted rate 0.31% |
| Healthcare-associated infections requiring hospitalization | 5.59% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 365 · Observed rate 3.84% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 11.03% |
8.2%
2.8 pts better
|
Numerator 46 · Denominator 417 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 40.28% |
56.45%
16.2 pts worse
|
Numerator 114 · Denominator 283 |
| Transfer of health information to provider | 48.1% |
95.95%
47.9 pts worse
|
Numerator 38 · Denominator 79 |
| Transfer of health information to patient | 99.21% |
96.28%
2.9 pts better
|
Numerator 250 · Denominator 252 |
| Resident COVID-19 vaccinations up to date | 34.52% |
25.2%
9.3 pts better
|
Numerator 58 · Denominator 168 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
2.3
1.9 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.9
2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
90.3%
1.3 pts worse
|
93.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 79.4% · Q3 81.6% · Q4 95.1% · 4Q avg 89.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.5% |
94.6%
8.1 pts worse
|
95.5%
9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.6% |
4.5%
3.1 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 5.9% · Q3 7.9% · Q4 7.3% · 4Q avg 7.6% · 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 | 3.5% |
3.6%
0.1 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 3.6% · Q4 3.6% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
25.3%
3.5 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 32.1% · Q3 21.4% · Q4 25.0% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
18.6%
3.7 pts better
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.5% · Q3 15.4% · Q4 14.8% · 4Q avg 14.9% · 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 | 20.7% |
15.5%
5.2 pts worse
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
14.1%
3.9 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.4% · Q3 0.0% · Q4 26.9% · 4Q avg 10.2% · 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 | 4.4% |
2.8%
1.6 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.2% · Q3 5.6% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.2% |
17.8%
4.6 pts better
|
19.8%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 15.4% · Q3 13.3% · Q4 20.6% · 4Q avg 13.2% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.1%
0.4 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 3.1% · Q3 0.0% · Q4 4.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.8% |
75.0%
19.2 pts worse
|
81.7%
25.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.1% · Q2 45.1% · Q3 50.9% · Q4 73.6% · 4Q avg 55.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
17.1%
3 pts better
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 13.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.9%
1.5 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 1.1% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 49.0% |
74.0%
25 pts worse
|
79.7%
30.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 49.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
27.0%
2 pts better
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 21.2% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-11 · Fire 2023-08-11
3 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-26 · Fire 2022-07-26
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-03
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 2024-11-08
E · Potential for more than minimal harm
2024-10-03
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 2024-11-08
E · Potential for more than minimal harm
2024-10-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-08
F · Potential for more than minimal harm
2022-07-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-25
E · Potential for more than minimal harm
2022-07-26
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 2022-08-25
E · Potential for more than minimal harm
2022-07-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-25
Inspection history
Recent health citations
J · Immediate jeopardy
2025-05-08
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 2025-05-01
D · Potential for more than minimal harm
2024-10-03
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-03
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-11-08
D · Potential for more than minimal harm
2023-08-11
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 2023-09-18
D · Potential for more than minimal harm
2023-08-11
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 2023-09-18
D · Potential for more than minimal harm
2023-08-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-18
G · Actual harm
2022-07-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-08-25
E · Potential for more than minimal harm
2022-07-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-25
E · Potential for more than minimal harm
2022-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-25
Penalties and ownership
What sits behind the stars
Ownership
Central Oklahoma United Methodist Retirement Facility Inc
5% Or Greater Direct Ownership Interest · Organization
Balogun, Seki
Operational/Managerial Control · Individual
Brown, Dawn
Corporate Officer · Individual
Caldwell, Victoria
Corporate Director · Individual
Compton, Vincent
Corporate Director · Individual
Craig, Rita
Corporate Officer · Individual
Cushman, Jennifer
Corporate Officer · Individual
Davis, Scott
Corporate Director · Individual
Ezell, Robert
Operational/Managerial Control · Individual
Ford, James
Corporate Director · Individual
Harter, Barbara
Operational/Managerial Control · Individual
Jean, Jacob
Corporate Director · Individual
Kelly, Ron
Corporate Officer · Individual
Knutson, Craig
Corporate Director · Individual
Logsdon, Kathy
Corporate Officer · Individual
Papin, Christopher
Corporate Director · Individual
Perry, Barbara
Corporate Director · Individual
Spinks, Robert
Corporate Director · Individual
Steele, Valerie
Corporate Director · Individual
Taylor, Edward
Corporate Officer · Individual
Unidine Corporation
Operational/Managerial Control · Organization
Watkins, Shane
Corporate Officer · Individual
Whitmire, Remonica
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Tuscany Village Nursing Center
Oklahoma City, OK
1-star overall rating with 2-star inspections with $25,626 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Parc Place Medical Resort
Oklahoma City, OK
2-star overall rating with 2-star inspections with $54,768 in total fines with 12 recent health deficiencies
#3
Edmond Health Care Center
Edmond, OK
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $84,723 in total fines with 27 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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