Cycle 1
Health 2024-06-20 · Fire 2024-06-20
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Edmond, OK
The Timbers Skilled Nursing And Therapy
4-star overall rating with 4-star inspections with $8,021 in total fines with 1 recent health deficiencies
2520 South Rankin, Edmond, OK
(405) 341-1433
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bridges Health
Operator or chain grouping
Approved since
1994-04-01
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
0.32
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.22
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.56
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,565
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.06
Baseline 26.78% · Performance 21.36% · Measure score 5.06 · Achievement 0 · Improvement 5.06
Healthcare-associated infections
2.46
Baseline 7.79% · Performance 7.10% · Measure score 2.46 · Achievement 2.46 · Improvement 1.96
Total nurse turnover
1.33
Baseline 58.82% · Performance 58.26% · Measure score 1.33 · Achievement 1.33 · Improvement 0
Adjusted total nurse staffing
2.92
Baseline 4.07 hours · Performance 3.91 hours · Measure score 2.92 · Achievement 2.92 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.78% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 12.24% · Lower 95% interval 7.8% |
| Discharge to community | 41.98% |
50.57%
8.6 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 36.36% · Lower 95% interval 31.81% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 86 · Denominator 86 |
| Falls with major injury | 2.33% |
0.77%
1.6 pts worse
|
Numerator 2 · Denominator 86 |
| Discharge self-care score | 75.44% |
53.69%
21.8 pts better
|
Numerator 43 · Denominator 57 |
| Discharge mobility score | 47.37% |
50.94%
3.6 pts worse
|
Numerator 27 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 6.98% |
2.29%
4.7 pts worse
|
Numerator 6 · Denominator 86 · Adjusted rate 6.34% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 62 · Observed rate 6.45% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 2.54% |
8.2%
5.7 pts worse
|
Numerator 3 · Denominator 118 |
| Staff flu vaccination coverage | 11.78% |
42%
30.2 pts worse
|
Numerator 47 · Denominator 399 |
| Discharge function score | 71.93% |
56.45%
15.5 pts better
|
Numerator 41 · Denominator 57 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 11.76% |
25.2%
13.4 pts worse
|
Numerator 6 · Denominator 51 |
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 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.9
0.3 pts better
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
90.3%
9.5 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
94.6%
0.1 pts better
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| 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 8.7% · Q2 5.8% · Q3 3.0% · Q4 3.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
3.3%
3 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
3.6%
1 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 2.5% · Q4 5.5% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
25.3%
5.8 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 23.6% · Q3 16.2% · Q4 14.3% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
18.6%
7.7 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 9.2% · Q3 11.3% · Q4 13.6% · 4Q avg 10.9% · 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 | 8.4% |
15.5%
7.1 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 5.2% · Q3 5.0% · Q4 11.3% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
14.1%
8.5 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.7% · Q3 3.8% · Q4 6.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.1%
1.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 1.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.8%
1.6 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 0.0% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
17.8%
1.7 pts better
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 10.8% · Q3 14.3% · Q4 19.7% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.1%
1.4 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.5% · Q3 6.2% · Q4 8.1% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
75.0%
24.4 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.1% |
17.1%
7 pts worse
|
12.0%
12.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 24.6% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.9%
1.6 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
74.0%
20.9 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.6% |
27.0%
8.6 pts worse
|
23.9%
11.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.6% · Observed 29.2% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-16 · Fire 2023-05-16
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-02-13 · Fire 2020-02-13
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-05-16
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 2023-07-25
E · Potential for more than minimal harm
2023-05-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-25
E · Potential for more than minimal harm
2020-02-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2020-03-24
E · Potential for more than minimal harm
2020-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-24
Inspection history
Recent health citations
J · Immediate jeopardy
2024-11-07
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 2024-10-25
F · Potential for more than minimal harm
2024-06-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-16
E · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-05-16
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 2023-06-14
E · Potential for more than minimal harm
2023-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-05-16
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 2023-06-14
E · Potential for more than minimal harm
2020-02-13
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 2020-03-24
E · Potential for more than minimal harm
2020-02-13
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2020-03-24
E · Potential for more than minimal harm
2020-02-13
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 2020-03-24
Penalties and ownership
What sits behind the stars
$8,021
2024-11-07
Fine
Fine · fine $8,021
Fine
Ownership
Bridges Employee Stock Ownership Trust
5% Or Greater Indirect Ownership Interest · Organization
Bridges Esop, Inc
5% Or Greater Direct Ownership Interest · Organization
Coble, William
Corporate Officer · Individual
Deroin, Kristy
Corporate Director · Individual
Griffin, William
Corporate Officer · Individual
Kenneth D. Greiner Iii Revocable Trust
5% Or Greater Security Interest · Organization
Martin, John
Operational/Managerial Control · Individual
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#2
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#3
Epworth Villa Health Services
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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