Tulsa, OK

The Cottage Extended Care

2-star overall rating with 2-star inspections with abuse icon flag with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

7707 South Memorial Drive, Tulsa, OK

(918) 250-8571

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

176

Certified beds

Average residents

84

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2005-10-01

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

0.22

Registered nurse staffing · state 0.34 · national 0.68

LPN hours / resident day

1.06

Licensed practical nurse staffing · state 0.92 · national 0.87

Aide hours / resident day

3.09

Nurse aide staffing · state 2.57 · national 2.35

Total nurse hours

4.37

All reported nurse hours · state 3.84 · national 3.89

Licensed hours

1.28

RN + LPN hours · state 1.27 · national 1.54

Weekend hours

3.70

Weekend nurse staffing · state 3.49 · national 3.43

Weekend RN hours

0.16

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

0.25

CMS adjusted RN staffing hours

Adjusted total hours

4.94

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

80%

Annual RN turnover · state 55% · national 45%

Total nurse turnover

73%

Annual nurse turnover · state 56% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,238

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

30.32

Composite VBP score used to determine payment impact.

Payment multiplier

0.9859

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.72

Baseline 21.42% · Performance 20.17% · Measure score 2.72 · Achievement 2.72 · Improvement 2.35

Healthcare-associated infections

5.56

Baseline 9.06% · Performance 6.60% · Measure score 5.56 · Achievement 4.14 · Improvement 5.56

Total nurse turnover

0

Baseline 68.89% · Performance 69.37% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

3.84

Baseline 4.55 hours · Performance 4.17 hours · Measure score 3.84 · Achievement 3.84 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.4%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 96 · Observed rate 15.63% · Lower 95% interval 8.19%
Discharge to community	53.2%	50.57% 2.6 pts better	No Different than the National Rate · Eligible stays 74 · Observed rate 44.59% · Lower 95% interval 43.57%
Medicare spending per beneficiary	1.06	1.02 About the same
Drug regimen review with follow-up	98.46%	95.27% 3.2 pts better	Numerator 64 · Denominator 65
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 65
Discharge self-care score	22.22%	53.69% 31.5 pts worse	Numerator 8 · Denominator 36
Discharge mobility score	13.89%	50.94% 37 pts worse	Numerator 5 · Denominator 36
Pressure ulcers or injuries, new or worsened	7.94%	2.29% 5.7 pts worse	Numerator 5 · Denominator 63 · Adjusted rate 7.41%
Healthcare-associated infections requiring hospitalization	6.6%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 3.99%
Staff COVID-19 vaccination coverage	25.78%	8.2% 17.6 pts better	Numerator 33 · Denominator 128
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 128
Discharge function score	22.22%	56.45% 34.2 pts worse	Numerator 8 · Denominator 36
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 29 · Denominator 29
Transfer of health information to patient	95.45%	96.28% 0.8 pts worse	Numerator 21 · Denominator 22
Resident COVID-19 vaccinations up to date	10.26%	25.2% 14.9 pts worse	Numerator 4 · Denominator 39

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	2.3 About the same	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	2.9 1 pts better	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.1 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	65.3%	90.3% 25 pts worse	93.4% 28.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 61.5% · Q2 58.0% · Q3 66.2% · Q4 76.8% · 4Q avg 65.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	81.1%	94.6% 13.5 pts worse	95.5% 14.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 81.1%
Percentage of long-stay residents experiencing one or more falls with major injury	0.6%	4.5% 3.9 pts better	3.3% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.9%	3.3% 1.4 pts better	11.4% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.9%
Percentage of long-stay residents who lose too much weight	2.2%	3.6% 1.4 pts better	5.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.4% · Q3 2.8% · Q4 0.0% · 4Q avg 2.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.1%	25.3% 13.2 pts better	19.6% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 12.0% · Q3 16.2% · Q4 9.7% · 4Q avg 12.1%
Percentage of long-stay residents who received an antipsychotic medication	14.9%	18.6% 3.7 pts better	16.7% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 13.8% · Q3 17.5% · Q4 17.9% · 4Q avg 14.9% · 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	2.5%	15.5% 13 pts better	16.3% 13.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 0.0% · Q4 4.8% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.4%	14.1% 8.7 pts better	14.9% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.0% · Q3 4.8% · Q4 8.3% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.6%	2.1% 0.5 pts worse	1.0% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 4.5% · Q4 4.0% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.0%	2.8% 1.8 pts better	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	12.8%	17.8% 5 pts better	19.8% 7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 15.4% · Q3 12.7% · Q4 6.3% · 4Q avg 12.8%
Percentage of long-stay residents with pressure ulcers	15.1%	5.1% 10 pts worse	5.1% 10 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.1% · Q3 15.6% · Q4 16.2% · 4Q avg 15.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	58.2%	75.0% 16.8 pts worse	81.7% 23.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 55.3% · Q2 42.7% · Q3 61.0% · Q4 75.6% · 4Q avg 58.2%
Percentage of short-stay residents who had an outpatient emergency department visit	17.4%	17.1% 0.3 pts worse	12.0% 5.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 21.2% · Expected 13.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.5%	1.9% 0.6 pts worse	1.6% 0.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 4.7% · Q3 4.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	40.8%	74.0% 33.2 pts worse	79.7% 38.9 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 40.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	35.1%	27.0% 8.1 pts worse	23.9% 11.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 35.1% · Observed 47.0% · Expected 31.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-09 · Fire 2025-01-09

4 health deficiencies

Top issue: Environmental (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-09-15 · Fire 2023-09-15

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2021-12-02 · Fire 2021-12-02

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-09

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 2025-02-24

E · Potential for more than minimal harm 2025-01-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-24

E · Potential for more than minimal harm 2025-01-09

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-02-24

E · Potential for more than minimal harm 2025-01-09

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2025-02-24

E · Potential for more than minimal harm 2025-01-09

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 2025-02-24

F · Potential for more than minimal harm 2023-09-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-04-20

F · Potential for more than minimal harm 2023-09-15

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2024-04-20

F · Potential for more than minimal harm 2023-09-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-20

E · Potential for more than minimal harm 2023-09-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-04-20

E · Potential for more than minimal harm 2023-09-15

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-04-20

E · Potential for more than minimal harm 2023-09-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-04-20

E · Potential for more than minimal harm 2021-12-02

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 2022-01-07

E · Potential for more than minimal harm 2021-12-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-01-07

E · Potential for more than minimal harm 2021-12-02

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-01-07

E · Potential for more than minimal harm 2021-12-02

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-01-07

Inspection history

Recent health citations

J · Immediate jeopardy 2025-05-30

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 2025-05-27

D · Potential for more than minimal harm 2025-01-09

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 2025-02-07

D · Potential for more than minimal harm 2025-01-09

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-09

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-02-07

E · Potential for more than minimal harm 2023-11-29

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 2023-12-26

D · Potential for more than minimal harm 2023-09-15

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2023-10-23

D · Potential for more than minimal harm 2023-09-15

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 2023-10-23

D · Potential for more than minimal harm 2023-09-15

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 2023-10-23

D · Potential for more than minimal harm 2023-09-15

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 2023-10-23

D · Potential for more than minimal harm 2023-09-15

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2023-10-23

E · Potential for more than minimal harm 2021-12-02

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 2022-02-21

E · Potential for more than minimal harm 2021-12-02

F570 · Resident Rights Deficiencies

Health

Assure the security of all personal funds of residents deposited with the facility.

Corrected 2022-02-21

E · Potential for more than minimal harm 2021-12-02

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2022-02-21

E · Potential for more than minimal harm 2021-12-02

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 2022-02-21

E · Potential for more than minimal harm 2021-12-02

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-02-21

E · Potential for more than minimal harm 2021-12-02

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 2022-02-21

D · Potential for more than minimal harm 2021-12-02

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2022-02-21

D · Potential for more than minimal harm 2021-12-02

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 2022-02-21

Penalties and ownership