Cycle 1
Health 2024-07-24 · Fire 2024-07-24
2 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Norman, OK
Holiday Heights Healthcare
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
301 East Dale, Norman, OK
(405) 321-7932
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
51
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
2020-04-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.02
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,361
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 57.14% · Performance 63.41% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.41
Baseline 3.92 hours · Performance 4.05 hours · Measure score 3.41 · Achievement 3.41 · Improvement 0.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 15.15% · Lower 95% interval 6.88% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.67% |
8.2%
1.5 pts worse
|
Numerator 3 · Denominator 45 |
| Staff flu vaccination coverage | 9.25% |
42%
32.8 pts worse
|
Numerator 16 · Denominator 173 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 10.9% |
4.5%
6.4 pts worse
|
3.3%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 13.3% · Q3 13.2% · Q4 10.3% · 4Q avg 10.9% · 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 | 2.9% |
3.6%
0.7 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.1% |
25.3%
14.8 pts worse
|
19.6%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.5% · Q2 38.9% · Q3 40.6% · Q4 41.7% · 4Q avg 40.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
18.6%
7.6 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 13.0% · Q3 9.1% · Q4 11.5% · 4Q avg 11.0% · 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 | 11.0% |
15.5%
4.5 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
14.1%
7.2 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 0.0% · Q3 10.0% · Q4 2.9% · 4Q avg 6.9% · 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 | 2.5% |
2.8%
0.3 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 2.5% · 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 12.1% · Q2 21.0% · Q3 15.0% · Q4 18.7% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.1%
2 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% · 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 · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.0% |
1.9%
5.1 pts worse
|
1.6%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-29 · Fire 2023-06-29
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-01-11 · Fire 2022-01-11
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-24
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-24
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-07-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-10
F · Potential for more than minimal harm
2023-06-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-06-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-06-29
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 2023-10-18
F · Potential for more than minimal harm
2023-06-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-06-29
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-06-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-06-29
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 2023-10-18
E · Potential for more than minimal harm
2023-06-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-06-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-18
C · Minimal harm
2023-06-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-18
C · Minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-18
C · Minimal harm
2023-06-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-18
F · Potential for more than minimal harm
2022-01-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-21
F · Potential for more than minimal harm
2022-01-11
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 2022-03-21
F · Potential for more than minimal harm
2022-01-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-03-17
E · Potential for more than minimal harm
2022-01-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-03-17
E · Potential for more than minimal harm
2022-01-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-03-17
E · Potential for more than minimal harm
2022-01-11
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 2022-03-21
E · Potential for more than minimal harm
2022-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-03-17
C · Minimal harm
2022-01-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-03-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-20
D · Potential for more than minimal harm
2024-07-24
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-20
E · Potential for more than minimal harm
2023-06-29
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 2023-08-09
D · Potential for more than minimal harm
2023-06-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-06-29
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 2023-08-09
E · Potential for more than minimal harm
2022-01-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-02-16
E · Potential for more than minimal harm
2022-01-11
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 2022-02-16
E · Potential for more than minimal harm
2022-01-11
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 2022-02-16
E · Potential for more than minimal harm
2022-01-11
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 2022-02-16
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
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
#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
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
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