Cycle 1
Health 2024-09-06 · Fire 2024-09-06
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Tulsa, OK
Sherwood Manor Nursing Home
1-star overall rating with 1-star inspections with abuse icon flag with $91,862 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2416 West 51stsouth, Tulsa, OK
(918) 446-4284
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
102
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-09-25
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
0.13
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
0.97
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.14
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
0.15
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.16
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
12,810
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.35
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 20.64% · Performance 23.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.03
Baseline 9.87% · Performance 8.64% · Measure score 2.03 · Achievement 0 · Improvement 2.03
Total nurse turnover
0
Baseline 71.43% · Performance 98.41% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.11
Baseline 4.20 hours · Performance 3.68 hours · Measure score 2.11 · Achievement 2.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.89% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 18.52% · Lower 95% interval 7.67% |
| Discharge to community | 45.64% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 35.71% · Lower 95% interval 30.94% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 62 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 10 · Denominator 40 |
| Discharge mobility score | 30% |
50.94%
20.9 pts worse
|
Numerator 12 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 62 · Adjusted rate 2.37% |
| Healthcare-associated infections requiring hospitalization | 8.64% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 15% · Lower 95% interval 5.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 70 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 35% |
56.45%
21.5 pts worse
|
Numerator 14 · Denominator 40 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 56% |
25.2%
30.8 pts better
|
Numerator 14 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.9
0.3 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 39.6% |
90.3%
50.7 pts worse
|
93.4%
53.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.3% · Q2 39.4% · Q3 37.9% · Q4 34.8% · 4Q avg 39.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.3% |
94.6%
16.3 pts worse
|
95.5%
17.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
4.5%
0.4 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 6.1% · Q4 8.7% · 4Q avg 4.1% · 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 | 0.0% |
3.6%
3.6 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 3.5% |
25.3%
21.8 pts better
|
19.6%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.6% · Q3 5.4% · Q4 3.6% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
18.6%
10.2 pts better
|
16.7%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 7.1% · Q3 9.5% · Q4 5.3% · 4Q avg 8.4% · 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 | 9.2% |
15.5%
6.3 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
14.1%
3 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 14.6% · Q3 22.4% · Q4 22.4% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.8% |
2.1%
4.7 pts worse
|
1.0%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.8% · Q3 6.7% · Q4 6.3% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.8%
2.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.5% |
17.8%
11.3 pts better
|
19.8%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 10.5% · Q3 3.4% · Q4 8.1% · 4Q avg 6.5% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.1%
2.8 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.1% · Q3 8.8% · Q4 5.6% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 4.8% |
75.0%
70.2 pts worse
|
81.7%
76.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.9% · Q3 3.1% · Q4 0.0% · 4Q avg 4.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
17.1%
6.7 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 11.8% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 5.7% |
74.0%
68.3 pts worse
|
79.7%
74 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 5.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
27.0%
4.3 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 23.5% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-04-22 · Fire 2021-04-22
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-06
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 2024-10-28
E · Potential for more than minimal harm
2023-08-03
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 2024-01-26
E · Potential for more than minimal harm
2021-04-22
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 2021-07-05
E · Potential for more than minimal harm
2021-04-22
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 2021-07-05
E · Potential for more than minimal harm
2021-04-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-05
Inspection history
Recent health citations
J · Immediate jeopardy
2025-04-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-25
J · Immediate jeopardy
2025-04-04
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-04
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-04-25
J · Immediate jeopardy
2024-09-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-28
E · Potential for more than minimal harm
2024-09-06
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 2024-10-28
E · Potential for more than minimal harm
2024-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-06
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-10-28
D · Potential for more than minimal harm
2024-09-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-06
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-06
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 2024-10-28
E · Potential for more than minimal harm
2024-06-25
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 2024-07-26
D · Potential for more than minimal harm
2024-06-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-26
E · Potential for more than minimal harm
2023-08-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-03
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 2023-09-08
D · Potential for more than minimal harm
2023-08-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-03
F657 · Resident Assessment and Care Planning Deficiencies
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 2023-09-08
D · Potential for more than minimal harm
2023-08-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-03
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 2023-09-08
D · Potential for more than minimal harm
2023-08-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-08
E · Potential for more than minimal harm
2021-04-22
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-06-10
E · Potential for more than minimal harm
2021-04-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-10
E · Potential for more than minimal harm
2021-04-22
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-04-22
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-04-22
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-06-10
Penalties and ownership
What sits behind the stars
$55,098
2025-04-04
Fine
Fine · fine $55,098
Fine
$36,764
2024-09-06
Fine
Fine · fine $36,764
Fine
$0
2024-09-06
Payment Denial
Payment Denial · denial start 2024-10-26 · 2 days
2 day denial
Ownership
Holland, Vernie
5% Or Greater Direct Ownership Interest · Individual
Holland, Vernie
Operational/Managerial Control · Individual
Holland, Whitney
5% Or Greater Direct Ownership Interest · Individual
Ponderosa Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
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