Shawnee, OK

The Regency Skilled Nursing And Therapy

5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1610 North Bryan Avenue, Shawnee, OK

(405) 275-9004

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 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

110

Certified beds

Average residents

89

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Bridges Health

Operator or chain grouping

Approved since

2007-01-31

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

0.28

Registered nurse staffing · state 0.34 · national 0.68

LPN hours / resident day

1.01

Licensed practical nurse staffing · state 0.92 · national 0.87

Aide hours / resident day

2.48

Nurse aide staffing · state 2.57 · national 2.35

Total nurse hours

3.76

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

3.36

Weekend nurse staffing · state 3.49 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.29 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.03 · national 0.07

Adjusted RN hours

0.31

CMS adjusted RN staffing hours

Adjusted total hours

4.19

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 55% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 56% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,111

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

Performance score

17.99

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 20.87% · Performance 22.76% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.23

Baseline 7.03% · Performance 7.47% · Measure score 1.23 · Achievement 1.23 · Improvement 0

Total nurse turnover

3.90

Baseline 62.38% · Performance 47.73% · Measure score 3.90 · Achievement 3.90 · Improvement 3.40

Adjusted total nurse staffing

2.07

Baseline 3.75 hours · Performance 3.67 hours · Measure score 2.07 · Achievement 2.07 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.15%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 250 · Observed rate 12% · Lower 95% interval 8.41%
Discharge to community	61.7%	50.57% 11.1 pts better	Better than the National Rate · Eligible stays 211 · Observed rate 59.24% · Lower 95% interval 56.58%
Medicare spending per beneficiary	0.99	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 212 · Denominator 212
Falls with major injury	1.89%	0.77% 1.1 pts worse	Numerator 4 · Denominator 212
Discharge self-care score	66.09%	53.69% 12.4 pts better	Numerator 76 · Denominator 115
Discharge mobility score	41.74%	50.94% 9.2 pts worse	Numerator 48 · Denominator 115
Pressure ulcers or injuries, new or worsened	3.3%	2.29% 1 pts worse	Numerator 7 · Denominator 212 · Adjusted rate 3.73%
Healthcare-associated infections requiring hospitalization	7.47%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 164 · Observed rate 7.32% · Lower 95% interval 5.14%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 116
Staff flu vaccination coverage	7.48%	42% 34.5 pts worse	Numerator 27 · Denominator 361
Discharge function score	47.83%	56.45% 8.6 pts worse	Numerator 55 · Denominator 115
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 92 · Denominator 92
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 101 · Denominator 101
Resident COVID-19 vaccinations up to date	10.81%	25.2% 14.4 pts worse	Numerator 12 · Denominator 111

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.9	2.3 0.4 pts better	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.9	2.9 2 pts worse	1.8 3.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.9 · Observed 3.8 · Expected 1.3 · 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	100.0%	94.6% 5.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.3%	4.5% 0.8 pts worse	3.3% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.0% · Q3 4.6% · Q4 3.3% · 4Q avg 5.3% · 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	5.1%	25.3% 20.2 pts better	19.6% 14.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.5% · Q3 6.7% · Q4 2.4% · 4Q avg 5.1%
Percentage of long-stay residents who received an antipsychotic medication	18.9%	18.6% 0.3 pts worse	16.7% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 18.9% · Q3 23.7% · Q4 16.7% · 4Q avg 18.9% · 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	11.2%	15.5% 4.3 pts better	16.3% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q3 27.6% · 4Q avg 11.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.2%	14.1% 8.9 pts better	14.9% 9.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.0% · Q3 6.8% · Q4 4.9% · 4Q avg 5.2% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 0.0% · Q3 1.5% · 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	17.0%	17.8% 0.8 pts better	19.8% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 12.6% · Q3 15.5% · Q4 22.9% · 4Q avg 17.0%
Percentage of long-stay residents with pressure ulcers	3.1%	5.1% 2 pts better	5.1% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.7% · Q3 1.3% · Q4 4.4% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.6%	75.0% 23.6 pts better	81.7% 16.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 99.1% · Q3 98.3% · Q4 98.4% · 4Q avg 98.6%
Percentage of short-stay residents who had an outpatient emergency department visit	24.9%	17.1% 7.8 pts worse	12.0% 12.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 24.4% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.7%	1.9% 0.2 pts better	1.6% 0.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 1.8% · Q4 2.4% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.6%	74.0% 22.6 pts better	79.7% 16.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.5%	27.0% 4.5 pts worse	23.9% 7.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 29.5% · Expected 22.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-01 · Fire 2025-05-01

1 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-01-05 · Fire 2024-01-05

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2023-02-08 · Fire 2023-02-08

13 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-05-01

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 2025-06-10

E · Potential for more than minimal harm 2025-05-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-06-10

F · Potential for more than minimal harm 2024-01-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-29

F · Potential for more than minimal harm 2024-01-05

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-05-29

F · Potential for more than minimal harm 2024-01-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-01-05

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 2024-05-29

E · Potential for more than minimal harm 2024-01-05

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-05-29

F · Potential for more than minimal harm 2023-02-08

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 2023-03-22

F · Potential for more than minimal harm 2023-02-08

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-03-22

E · Potential for more than minimal harm 2023-02-08

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 2023-03-22

C · Minimal harm 2023-02-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-03-22

C · Minimal harm 2023-02-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-22

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-10

D · Potential for more than minimal harm 2024-01-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-01-31

D · Potential for more than minimal harm 2024-01-05

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 2024-01-31

E · Potential for more than minimal harm 2023-08-30

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-08-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-03-16

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2023-03-22

E · Potential for more than minimal harm 2023-02-08

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 2023-03-22

E · Potential for more than minimal harm 2023-02-08