8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Oklahoma City, OK
2-star overall rating with 2-star inspections with abuse icon flag with $70,695 in total fines with 8 recent health deficiencies
3233 Northwest 10th Street, Oklahoma City, OK
(405) 943-8366
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
125
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
1995-02-01
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
RN hours / resident day
0.43
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.33
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
5.47
CMS adjusted total nurse staffing hours
Case-mix index
1.00
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Program rank
10,105
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 22.10% · Performance 22.16% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.22
Baseline 9.54% · Performance 7.40% · Measure score 4.22 · Achievement 1.47 · Improvement 4.22
Total nurse turnover
1.17
Baseline 50.65% · Performance 58.89% · Measure score 1.17 · Achievement 1.17 · Improvement 0
Adjusted total nurse staffing
3.18
Baseline 3.93 hours · Performance 3.98 hours · Measure score 3.18 · Achievement 3.18 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.83% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 9.89% · Lower 95% interval 7.28% |
| Discharge to community | 47.47% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 38.36% · Lower 95% interval 36.09% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 40 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 14 · Denominator 28 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 21 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 0.94% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 106 |
| Staff flu vaccination coverage | 10.5% |
42%
31.5 pts worse
|
Numerator 38 · Denominator 362 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 16 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.3
0.4 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.9
0.2 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
90.3%
8.9 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.9% · Q3 100.0% · Q4 98.8% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.6%
3.5 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
4.5%
1.5 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.3% · Q3 4.5% · Q4 6.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
3.3%
2.7 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
3.6%
0.9 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.5% · Q3 1.3% · Q4 5.5% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
25.3%
8.3 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 15.1% · Q3 14.3% · Q4 20.5% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
18.6%
1.2 pts worse
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 20.3% · Q3 21.4% · Q4 20.8% · 4Q avg 19.8% · 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 | 12.7% |
15.5%
2.8 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 18.2% · Q3 8.6% · Q4 12.0% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
14.1%
5.1 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 14.8% · Q3 4.2% · Q4 8.6% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
2.1%
0.3 pts better
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.9% · Q3 3.0% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.8%
2.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
17.8%
8.3 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 28.2% · Q3 31.4% · Q4 28.0% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.1%
1.4 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.6% · Q3 8.7% · Q4 5.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
75.0%
14.6 pts better
|
81.7%
7.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.0% · Q2 88.9% · Q3 100.0% · Q4 98.6% · 4Q avg 89.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.9% |
17.1%
6.8 pts worse
|
12.0%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 27.5% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.9%
0.6 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 5.6% · Q4 4.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
74.0%
14.9 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
27.0%
5.7 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 22.5% · Expected 25.1% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-11
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 2023-10-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-11
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-15
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 2021-12-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-15
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-08
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-08
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-08
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-08
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 2025-08-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-11
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-08
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-23
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-08-28
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-08-28
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-16
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-16
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-08-16
Health
Assess the resident when there is a significant change in condition
Corrected 2023-08-16
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-16
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-16
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-16
Penalties and ownership
Fine · fine $57,960
Fine
Fine · fine $12,735
Fine
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
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