Cycle 1
Health 2024-05-16 · Fire 2024-05-16
3 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Norman, OK
Grace Skilled And Nursing Therapy Norman
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4554 West Main, Norman, OK
(405) 366-8800
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
136
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
1992-06-01
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
0.44
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,715
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.88% · Performance 23.49% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.49% · Performance 8.45% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.73
Baseline 40.96% · Performance 56.60% · Measure score 1.73 · Achievement 1.73 · Improvement 0
Adjusted total nurse staffing
2.63
Baseline 3.85 hours · Performance 3.83 hours · Measure score 2.63 · Achievement 2.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.15% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 395 · Observed rate 13.42% · Lower 95% interval 10.31% |
| Discharge to community | 50.89% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 332 · Observed rate 48.49% · Lower 95% interval 45.29% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 267 · Denominator 267 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 2 · Denominator 266 |
| Discharge self-care score | 38.59% |
53.69%
15.1 pts worse
|
Numerator 71 · Denominator 184 |
| Discharge mobility score | 45.65% |
50.94%
5.3 pts worse
|
Numerator 84 · Denominator 184 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 3 · Denominator 267 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 8.45% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 236 · Observed rate 8.47% · Lower 95% interval 5.7% |
| Staff COVID-19 vaccination coverage | 1.61% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 124 |
| Staff flu vaccination coverage | 16.14% |
42%
25.9 pts worse
|
Numerator 66 · Denominator 409 |
| Discharge function score | 41.3% |
56.45%
15.2 pts worse
|
Numerator 76 · Denominator 184 |
| Transfer of health information to provider | 98.57% |
95.95%
2.6 pts better
|
Numerator 138 · Denominator 140 |
| Transfer of health information to patient | 98.97% |
96.28%
2.7 pts better
|
Numerator 96 · Denominator 97 |
| Resident COVID-19 vaccinations up to date | 17.48% |
25.2%
7.7 pts worse
|
Numerator 25 · Denominator 143 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.9
2.5 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.3 · 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 | 98.9% |
94.6%
4.3 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
4.5%
1.4 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.4% · Q3 2.6% · Q4 2.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
3.3%
3 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
3.6%
3.2 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.9% |
25.3%
3.4 pts better
|
19.6%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 20.3% · Q3 23.1% · Q4 27.1% · 4Q avg 21.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
18.6%
7.2 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 14.3% · Q3 13.7% · Q4 9.3% · 4Q avg 11.4% · 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 | 19.5% |
15.5%
4 pts worse
|
16.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 25.9% · Q3 29.2% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
14.1%
4.4 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.6% · Q3 11.3% · Q4 5.9% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
2.1%
1.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.8%
1.5 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.2% · Q3 0.0% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
17.8%
1 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 18.0% · Q3 14.7% · Q4 14.3% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.1%
0.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.1% · Q3 6.6% · Q4 2.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
75.0%
25 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
17.1%
6.5 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 10.6% · Expected 11.1% · 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 0.6% · Q2 1.2% · Q3 1.6% · Q4 2.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
74.0%
21.9 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
27.0%
1.6 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 26.0% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-06 · Fire 2023-04-06
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-11-10 · Fire 2021-11-10
5 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-05-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-05-16
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 2024-07-30
E · Potential for more than minimal harm
2024-05-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-05-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-30
F · Potential for more than minimal harm
2023-04-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-06
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 2023-05-30
E · Potential for more than minimal harm
2023-04-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-04-06
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 2023-05-30
F · Potential for more than minimal harm
2021-11-10
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 2021-12-21
F · Potential for more than minimal harm
2021-11-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-21
E · Potential for more than minimal harm
2021-11-10
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 2021-12-21
E · Potential for more than minimal harm
2021-11-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-12-21
E · Potential for more than minimal harm
2021-11-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-21
E · Potential for more than minimal harm
2021-11-10
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 2021-12-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-16
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 2024-06-05
D · Potential for more than minimal harm
2024-05-16
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 2024-06-05
D · Potential for more than minimal harm
2024-05-16
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-06-05
E · Potential for more than minimal harm
2023-04-06
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 2023-05-30
E · Potential for more than minimal harm
2023-04-06
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 2023-05-30
D · Potential for more than minimal harm
2023-04-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-30
E · Potential for more than minimal harm
2021-11-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2021-12-21
E · Potential for more than minimal harm
2021-11-10
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 2021-12-21
E · Potential for more than minimal harm
2021-11-10
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 2021-12-21
D · Potential for more than minimal harm
2021-11-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-21
D · Potential for more than minimal harm
2021-11-10
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 2021-12-21
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
Contracted Managing Employee · Individual
Deroin, Kristy
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Medical Park West Rehabilitation & Skilled Care
Norman, OK
1-star overall rating with 1-star inspections with Special Focus status with $21,962 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Ignite Medical Resort Norman, Llc
Norman, OK
1-star overall rating with 1-star inspections with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
24th Place
Norman, OK
1-star overall rating with 1-star inspections with $35,660 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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