Cycle 1
Health 2024-10-31 · Fire 2024-10-31
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tulsa, OK
Oklahoma Memory Care Institute
2-star overall rating with 2-star inspections with $8,653 in total fines with 9 recent health deficiencies
3333 East 28th Street, Tulsa, OK
(918) 203-0606
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
56
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Diakonos Group
Operator or chain grouping
Approved since
2004-10-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing
LPN hours / resident day
0.99
Licensed practical nurse staffing
Aide hours / resident day
2.25
Nurse aide staffing
Weekend hours
3.33
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.9
0.8 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 64.8% |
90.3%
25.5 pts worse
|
93.4%
28.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 74.5% |
94.6%
20.1 pts worse
|
95.5%
21 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
4.5%
2.2 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 4.5% |
3.6%
0.9 pts worse
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 50.5% |
25.3%
25.2 pts worse
|
19.6%
30.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
18.6%
12.7 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.4% |
15.5%
7.9 pts worse
|
16.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.8% |
14.1%
20.7 pts worse
|
14.9%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.8%
1.6 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.1% |
17.8%
14.3 pts worse
|
19.8%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.1%
2.2 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.2% |
75.0%
30.8 pts worse
|
81.7%
37.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.1% |
1.9%
4.2 pts worse
|
1.6%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
17 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-10-20 · Fire 2022-10-20
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
E · Potential for more than minimal harm
2023-09-22
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-05-31
D · Potential for more than minimal harm
2023-09-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-31
C · Minimal harm
2023-09-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-31
F · Potential for more than minimal harm
2022-10-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-08
F · Potential for more than minimal harm
2022-10-20
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-20
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 2022-11-08
C · Minimal harm
2022-10-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-08
Inspection history
Recent health citations
J · Immediate jeopardy
2025-02-11
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 2025-01-31
D · Potential for more than minimal harm
2025-01-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-10-31
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 2024-12-05
E · Potential for more than minimal harm
2024-10-31
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 2024-12-05
E · Potential for more than minimal harm
2024-10-31
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-31
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-31
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 2024-12-05
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-31
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-16
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-16
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-11-15
E · Potential for more than minimal harm
2023-09-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-22
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-22
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 2023-10-25
E · Potential for more than minimal harm
2023-09-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-22
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-22
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 2023-10-25
E · Potential for more than minimal harm
2023-09-22
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-22
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-22
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 2023-10-25
D · Potential for more than minimal harm
2023-09-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-22
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-25
E · Potential for more than minimal harm
2022-10-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-20
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 2022-11-08
D · Potential for more than minimal harm
2022-10-20
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 2022-11-08
Penalties and ownership
What sits behind the stars
$8,653
2025-01-29
Fine
Fine · fine $8,653
Fine
Ownership
Diakonos Group, LLC
5% Or Greater Direct Ownership Interest · Organization
Pilgrim, Scott
5% Or Greater Indirect Ownership Interest · Individual
Bush, William
Operational/Managerial Control · Individual
Diakonos Group, LLC
Operational/Managerial Control · Organization
Pilgrim, Scott
Corporate Officer · Individual
Rife, Michael
Operational/Managerial Control · Individual
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5-star overall rating with 5-star inspections
#2
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2-star overall rating with 2-star inspections with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Southern Hills Rehabilitation Center
Tulsa, OK
2-star overall rating with 2-star inspections with $15,766 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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