Cycle 1
Health 2025-09-18 · Fire 2025-09-18
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Colbert, OK
Southern Pointe Living Center
1-star overall rating with 1-star inspections with abuse icon flag with $49,921 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
101 Sherrard Drive, Colbert, OK
(580) 296-4500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bgm Estate
Operator or chain grouping
Approved since
2004-09-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 2 overall / 3 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
0.16
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
1.34
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
2.04
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
0.70
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
1.93
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.21
CMS adjusted RN staffing hours
Adjusted total hours
2.64
CMS adjusted total nurse staffing hours
Case-mix index
1.05
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
86%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,640
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.79
Baseline 25.02% · Performance 18.40% · Measure score 7.79 · Achievement 6.55 · Improvement 7.79
Healthcare-associated infections
1.43
Baseline 8.02% · Performance 7.44% · Measure score 1.43 · Achievement 1.33 · Improvement 1.43
Total nurse turnover
0
Performance 80.64% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.85 hours · Performance 2.52 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.59% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 21.05% · Lower 95% interval 9.02% |
| Discharge to community | 44.7% |
50.57%
5.9 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 31.25% · Lower 95% interval 29.38% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 82.93% |
95.27%
12.3 pts worse
|
Numerator 34 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 21.74% |
53.69%
31.9 pts worse
|
Numerator 5 · Denominator 23 |
| Discharge mobility score | 21.74% |
50.94%
29.2 pts worse
|
Numerator 5 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 9.76% |
2.29%
7.5 pts worse
|
Numerator 4 · Denominator 41 · Adjusted rate 8.39% |
| Healthcare-associated infections requiring hospitalization | 7.44% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 39 |
| Staff flu vaccination coverage | 5.66% |
42%
36.3 pts worse
|
Numerator 6 · Denominator 106 |
| Discharge function score | 26.09% |
56.45%
30.4 pts worse
|
Numerator 6 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 29.17% |
25.2%
4 pts better
|
Numerator 7 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.3
1.3 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 4.7 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.9
1.1 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.5 · Expected 2.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
90.3%
1 pts better
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 97.5% · Q3 78.0% · Q4 92.5% · 4Q avg 91.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.1% |
94.6%
10.5 pts worse
|
95.5%
11.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
4.5%
1.1 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.5% · Q3 2.4% · Q4 5.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
3.3%
2.4 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
3.6%
0.8 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.3% · Q3 0.0% · Q4 8.3% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.3% |
25.3%
4 pts worse
|
19.6%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 36.1% · Q3 26.3% · Q4 28.9% · 4Q avg 29.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.8% |
18.6%
17.2 pts worse
|
16.7%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 42.9% · Q3 34.5% · Q4 29.4% · 4Q avg 35.8% · 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 | 22.4% |
15.5%
6.9 pts worse
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 27.3% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.6% |
14.1%
10.5 pts worse
|
14.9%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 38.2% · Q3 25.0% · Q4 17.1% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
2.1%
About the same
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 1.7% · Q4 1.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.8%
0.8 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.6% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.2% |
17.8%
0.6 pts better
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 25.2% · Q3 11.7% · Q4 4.7% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 11.2% |
5.1%
6.1 pts worse
|
5.1%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 8.6% · Q3 13.8% · Q4 6.5% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
75.0%
14 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 86.4% · Q3 87.0% · Q4 89.7% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.6% |
17.1%
3.5 pts worse
|
12.0%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 26.2% · Expected 14.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
1.9%
3.7 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.3% |
74.0%
3.3 pts better
|
79.7%
2.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.9% |
27.0%
8.9 pts worse
|
23.9%
12 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.9% · Observed 45.2% · Expected 30.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-14 · Fire 2023-01-14
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-09-18
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-12-05
C · Minimal harm
2025-09-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-18
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 2025-10-13
J · Immediate jeopardy
2025-04-08
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 2025-04-09
J · Immediate jeopardy
2025-04-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-09
E · Potential for more than minimal harm
2024-04-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-20
E · Potential for more than minimal harm
2024-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-20
E · Potential for more than minimal harm
2024-04-04
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-04
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-04
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 2024-05-20
D · Potential for more than minimal harm
2024-04-04
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-04
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 2024-05-20
D · Potential for more than minimal harm
2024-04-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-04
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-01-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-02
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 2024-02-01
D · Potential for more than minimal harm
2024-01-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
L · Immediate jeopardy
2023-05-22
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 2023-05-30
F · Potential for more than minimal harm
2023-05-22
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-22
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
2023-01-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-14
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 2023-02-28
E · Potential for more than minimal harm
2023-01-14
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 2023-02-28
E · Potential for more than minimal harm
2023-01-14
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-14
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 2023-02-28
D · Potential for more than minimal harm
2023-01-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-28
Penalties and ownership
What sits behind the stars
$38,445
2025-04-08
Fine
Fine · fine $38,445
Fine
$11,476
2023-05-22
Fine
Fine · fine $11,476
Fine
Ownership
Philip M. Green Revocable Trust
5% Or Greater Direct Ownership Interest · Organization
Mitchell, Kelly
5% Or Greater Direct Ownership Interest · Individual
Mitchell, Marcinda
5% Or Greater Direct Ownership Interest · Individual
Mitchell, Robert
5% Or Greater Direct Ownership Interest · Individual
Tabor, Angela
5% Or Greater Direct Ownership Interest · Individual
Bypass Tr Cu Gilbert F Green Tr
5% Or Greater Direct Ownership Interest · Organization
Tiffany Seay Exempt Tr
5% Or Greater Direct Ownership Interest · Organization
Mrtl Deduction Tr Cu Gilbert F Green Tr
5% Or Greater Direct Ownership Interest · Organization
Philip Marion Green Exempt Tr Cu Gilbert F Green Tr
5% Or Greater Direct Ownership Interest · Organization
Belt, Miranda
Corporate Officer · Individual
Pitts, Jaci
Corporate Officer · Individual
Taylor, Sandra
W-2 Managing Employee · Individual
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#2
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#3
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