Cycle 1
Health 2024-05-17 · Fire 2024-05-17
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Oklahoma City, OK
St. Ann's Skilled Nursing And Therapy
4-star overall rating with 4-star inspections with 8 recent health deficiencies
9400 St Ann's Drive, Oklahoma City, OK
(405) 728-7888
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
2014-05-01
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.24
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.71
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,317
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.16% · Performance 22.03% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.46
Baseline 9.59% · Performance 7.78% · Measure score 3.46 · Achievement 0 · Improvement 3.46
Total nurse turnover
1.69
Baseline 58.24% · Performance 56.76% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Adjusted total nurse staffing
4.45
Baseline 3.95 hours · Performance 4.34 hours · Measure score 4.45 · Achievement 4.45 · Improvement 1.64
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 9.6% · Lower 95% interval 7.68% |
| Discharge to community | 49.77% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 46.51% · Lower 95% interval 42.01% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.47% |
95.27%
2.2 pts better
|
Numerator 154 · Denominator 158 |
| Falls with major injury | 1.9% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 158 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 50 · Denominator 100 |
| Discharge mobility score | 35% |
50.94%
15.9 pts worse
|
Numerator 35 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 1.27% |
2.29%
1 pts better
|
Numerator 2 · Denominator 158 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 7.78% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 8.49% · Lower 95% interval 5.18% |
| Staff COVID-19 vaccination coverage | 1.6% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 125 |
| Staff flu vaccination coverage | 18.14% |
42%
23.9 pts worse
|
Numerator 76 · Denominator 419 |
| Discharge function score | 46% |
56.45%
10.5 pts worse
|
Numerator 46 · Denominator 100 |
| Transfer of health information to provider | 88.66% |
95.95%
7.3 pts worse
|
Numerator 86 · Denominator 97 |
| Transfer of health information to patient | 73.53% |
96.28%
22.8 pts worse
|
Numerator 25 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 25.3% |
25.2%
0.1 pts better
|
Numerator 21 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.9
0.1 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| 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 | 97.8% |
94.6%
3.2 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
4.5%
0.3 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 6.7% · Q4 7.2% · 4Q avg 4.8% · 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 | 0.8% |
3.6%
2.8 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
25.3%
5 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 20.6% · Q3 15.7% · Q4 17.5% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
18.6%
11.2 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.2% · Q3 5.4% · Q4 10.9% · 4Q avg 7.4% · 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 | 7.9% |
15.5%
7.6 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 14.1% · Q3 0.0% · Q4 3.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
14.1%
7.9 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 4.8% · Q3 2.9% · Q4 7.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.1%
1 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.9% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.8%
2.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
17.8%
1.5 pts better
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 19.0% · Q3 14.0% · Q4 18.1% · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.1%
1 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.5% · Q3 10.7% · Q4 2.8% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
75.0%
24.5 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.0% · Q3 99.5% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.7% |
17.1%
2.6 pts worse
|
12.0%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 19.4% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.9%
1.1 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
74.0%
10.8 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.9% |
27.0%
6.9 pts worse
|
23.9%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.9% · Observed 31.5% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-03 · Fire 2023-04-03
3 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-11-13 · Fire 2019-11-13
11 health deficiencies
Top issue: Administration (2 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
2023-04-03
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 2023-06-21
E · Potential for more than minimal harm
2023-04-03
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 2023-06-21
E · Potential for more than minimal harm
2023-04-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2025-06-12
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 2025-07-15
D · Potential for more than minimal harm
2025-06-12
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 2025-07-15
D · Potential for more than minimal harm
2025-06-12
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 2025-07-15
D · Potential for more than minimal harm
2024-05-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-17
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 2024-06-19
D · Potential for more than minimal harm
2024-05-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-19
E · Potential for more than minimal harm
2023-04-03
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 2023-05-30
D · Potential for more than minimal harm
2023-04-03
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 2023-05-30
D · Potential for more than minimal harm
2023-04-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-05-30
E · Potential for more than minimal harm
2019-11-13
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 2019-12-18
E · Potential for more than minimal harm
2019-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-18
E · Potential for more than minimal harm
2019-11-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-12-18
E · Potential for more than minimal harm
2019-11-13
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 2019-12-18
E · Potential for more than minimal harm
2019-11-13
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-12-18
E · Potential for more than minimal harm
2019-11-13
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 2019-12-18
D · Potential for more than minimal harm
2019-11-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-13
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-18
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
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Health Center At Concordia
Oklahoma City, OK
5-star overall rating with 4-star inspections with $25,407 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Baptist Village of Oklahoma City
Oklahoma City, OK
2-star overall rating with 2-star inspections with abuse icon flag with $34,272 in total fines with 2 recent health deficiencies
#3
The Lakes
Oklahoma City, OK
1-star overall rating with 2-star inspections with $19,073 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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