Cycle 1
Health 2024-07-03 · Fire 2024-07-03
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tulsa, OK
Trinity Woods, Inc.
5-star overall rating with 5-star inspections
4134 East 31st Street, Tulsa, OK
(918) 743-2565
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing
LPN hours / resident day
1.39
Licensed practical nurse staffing
Aide hours / resident day
3.50
Nurse aide staffing
Weekend hours
5.00
Weekend nurse staffing
RN turnover
14%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.3
1.6 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.9
1.7 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
90.3%
8.5 pts worse
|
93.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.1% |
94.6%
3.5 pts worse
|
95.5%
4.4 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
4.5%
2.5 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 7.3% |
3.6%
3.7 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
18.6%
14.2 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.7% |
15.5%
8.2 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
14.1%
6.1 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
2.8%
1.3 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
17.8%
0.5 pts better
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.1%
0.7 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.6% |
75.0%
1.4 pts worse
|
81.7%
8.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
17.1%
10 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.3% |
74.0%
11.7 pts worse
|
79.7%
17.4 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
27.0%
2.1 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-15 · Fire 2023-06-15
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-12-06 · Fire 2019-12-06
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-12-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-17
E · Potential for more than minimal harm
2019-12-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-02-06
E · Potential for more than minimal harm
2019-12-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-02-06
E · Potential for more than minimal harm
2019-12-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-02-06
E · Potential for more than minimal harm
2019-12-06
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 2020-02-06
Penalties and ownership
What sits behind the stars
Ownership
Trinity Woods
5% Or Greater Direct Ownership Interest · Organization
Creswell, Emilie
Operational/Managerial Control · Individual
Lee, Garrett
Corporate Officer · Individual
Steele, Jerome
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Oklahoma Memory Care Institute
Tulsa, OK
2-star overall rating with 2-star inspections with $8,653 in total fines with 9 recent health deficiencies
#2
Gracewood Health & Rehab
Tulsa, OK
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Southern Hills Rehabilitation Center
Tulsa, OK
2-star overall rating with 2-star inspections with $15,766 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out