Cycle 1
Health 2025-08-22 · Fire 2025-08-22
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Marlow, OK
Gregston Nursing Home, Inc.
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
711 South Broadway, Marlow, OK
(580) 658-2319
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
96
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.18
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.50
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.33
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
5.01
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
4.53
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.17
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
0.22
CMS adjusted RN staffing hours
Adjusted total hours
5.88
CMS adjusted total nurse staffing hours
Case-mix index
1.17
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
10,220
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.51% · Performance 23.94% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.92% · Performance 8.50% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.33
Baseline 5.01 hours · Performance 4.88 hours · Measure score 6.33 · Achievement 6.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.3% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 10.74% · Lower 95% interval 7.49% |
| Discharge to community | 56.02% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 55.17% · Lower 95% interval 49.1% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 88 · Denominator 88 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 88 |
| Discharge self-care score | 56.67% |
53.69%
3 pts better
|
Numerator 34 · Denominator 60 |
| Discharge mobility score | 68.33% |
50.94%
17.4 pts better
|
Numerator 41 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 3.41% |
2.29%
1.1 pts worse
|
Numerator 3 · Denominator 88 · Adjusted rate 4.1% |
| Healthcare-associated infections requiring hospitalization | 8.5% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 10% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 2.02% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 99 |
| Staff flu vaccination coverage | 23.3% |
42%
18.7 pts worse
|
Numerator 24 · Denominator 103 |
| Discharge function score | 63.33% |
56.45%
6.9 pts better
|
Numerator 38 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 69 · Denominator 69 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.35% |
25.2%
20.9 pts worse
|
Numerator 2 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.9 |
2.3
1.6 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
2.9
1 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.3% |
90.3%
13 pts worse
|
93.4%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 79.5% · Q3 73.3% · Q4 69.0% · 4Q avg 77.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
94.6%
3.1 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.2% |
4.5%
5.7 pts worse
|
3.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.4% · Q3 6.7% · Q4 11.9% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
3.3%
0.3 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
3.6%
0.2 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 3.0% · Q4 3.6% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
25.3%
2.8 pts better
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 19.4% · Q3 27.3% · Q4 23.5% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
18.6%
5.9 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 23.1% · Q3 27.6% · Q4 18.5% · 4Q avg 24.5% · 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 | 27.9% |
14.1%
13.8 pts worse
|
14.9%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 27.6% · Q3 31.2% · Q4 43.8% · 4Q avg 27.9% · 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 | 3.0% |
2.8%
0.2 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.9% · Q3 4.4% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
17.8%
4.9 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 29.9% · Q3 18.6% · Q4 21.0% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.1%
3.3 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 1.6% · Q4 2.5% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 19.0% |
75.0%
56 pts worse
|
81.7%
62.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 32.2% · Q2 22.2% · Q3 11.1% · Q4 11.8% · 4Q avg 19.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.4% |
17.1%
5.3 pts worse
|
12.0%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 19.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.9%
0.6 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 2.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.8% |
74.0%
48.2 pts worse
|
79.7%
53.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.5% |
27.0%
3.5 pts worse
|
23.9%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 24.5% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-01-13 · Fire 2023-01-13
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-22
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 2025-10-01
E · Potential for more than minimal harm
2025-08-22
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-08-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-01
E · Potential for more than minimal harm
2024-03-07
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-01-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-17
F · Potential for more than minimal harm
2023-01-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-01-13
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 2023-04-05
E · Potential for more than minimal harm
2023-01-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-01-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-05
C · Minimal harm
2023-01-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-04-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-22
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 2025-10-01
E · Potential for more than minimal harm
2025-08-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-01
E · Potential for more than minimal harm
2023-01-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-01-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-24
Penalties and ownership
What sits behind the stars
Ownership
Gregston, Jeff
5% Or Greater Direct Ownership Interest · Individual
Gregston, Jillian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Marlow Nursing & Rehab
Marlow, OK
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Wilkins Health & Rehabilitation Community
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4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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