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
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
0.54
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.50
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
5.43
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
5.00
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.47
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
0.61
CMS adjusted RN staffing hours
Adjusted total hours
6.06
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,535
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9969
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.78
Baseline 23.29% · Performance 19.98% · Measure score 4.78 · Achievement 3.12 · Improvement 4.78
Healthcare-associated infections
0
Baseline 7.24% · Performance 8.21% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.76
Baseline 47.92% · Performance 52.38% · Measure score 2.76 · Achievement 2.76 · Improvement 0
Adjusted total nurse staffing
10
Baseline 4.72 hours · Performance 5.91 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 6.45% · Lower 95% interval 6.3% |
| Discharge to community | 55.48% |
50.57%
4.9 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 52.78% · Lower 95% interval 47.45% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.22% |
95.27%
2 pts better
|
Numerator 70 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 60.71% |
53.69%
7 pts better
|
Numerator 34 · Denominator 56 |
| Discharge mobility score | 69.64% |
50.94%
18.7 pts better
|
Numerator 39 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 3 · Denominator 72 · Adjusted rate 5.18% |
| Healthcare-associated infections requiring hospitalization | 8.21% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 9.52% |
8.2%
1.3 pts better
|
Numerator 22 · Denominator 231 |
| Staff flu vaccination coverage | 28.33% |
42%
13.7 pts worse
|
Numerator 66 · Denominator 233 |
| Discharge function score | 78.57% |
56.45%
22.1 pts better
|
Numerator 44 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 28 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 51.35% |
25.2%
26.2 pts better
|
Numerator 19 · Denominator 37 |
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 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| 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 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 86.3% · Q2 82.6% · Q3 84.0% · Q4 74.5% · 4Q avg 81.8% |
| 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 · 4Q avg 91.1% |
| 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 · Q1 2.0% · Q2 4.3% · Q3 2.0% · Q4 0.0% · 4Q avg 2.0% · 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 | 7.3% |
3.6%
3.7 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 5.7% · Q3 2.6% · Q4 2.4% · 4Q avg 7.3% |
| 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 14.7% · Q2 19.4% · Q3 19.5% · Q4 26.2% · 4Q avg 20.3% |
| 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 · Q1 6.9% · Q2 3.7% · Q3 3.3% · Q4 3.6% · 4Q avg 4.4% · 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 | 23.7% |
15.5%
8.2 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.7% · Used in QM five-star |
| 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 · Q1 28.1% · Q2 25.8% · Q3 6.2% · Q4 20.7% · 4Q avg 20.2% · 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 | 4.1% |
2.8%
1.3 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star |
| 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 · Q1 19.3% · Q2 13.5% · Q3 17.9% · Q4 18.5% · 4Q avg 17.3% |
| 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 · Q1 5.9% · Q2 4.0% · Q3 2.1% · Q4 5.4% · 4Q avg 4.4% · Used in QM five-star |
| 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 · Q1 85.4% · Q2 72.9% · Q3 69.5% · Q4 69.8% · 4Q avg 73.6% |
| 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 · Adjusted 7.1% · Observed 6.5% · Expected 10.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 62.3% |
| 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 · Adjusted 24.9% · Observed 19.4% · Expected 18.5% · Used in QM five-star |
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