Cycle 1
Health 2024-12-05 · Fire 2024-12-05
8 health deficiencies
Top issue: Administration (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tulsa, OK
University Village Retirement Community
3-star overall rating with 3-star inspections with 8 recent health deficiencies
8555 South Lewis Avenue, Tulsa, OK
(918) 299-2661
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-06-05
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
0.84
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
4.05
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
4.67
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,396
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.70
Baseline 21.63% · Performance 20.64% · Measure score 1.70 · Achievement 1.70 · Improvement 1.64
Healthcare-associated infections
4.34
Baseline 6.42% · Performance 6.54% · Measure score 4.34 · Achievement 4.34 · Improvement 0
Total nurse turnover
2.57
Baseline 71.90% · Performance 57.47% · Measure score 2.57 · Achievement 1.52 · Improvement 2.57
Adjusted total nurse staffing
5.93
Baseline 4.74 hours · Performance 4.77 hours · Measure score 5.93 · Achievement 5.93 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.53% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 7.55% · Lower 95% interval 6.89% |
| Discharge to community | 36.16% |
50.57%
14.4 pts worse
|
Worse than the National Rate · Eligible stays 170 · Observed rate 31.76% · Lower 95% interval 29.31% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 104 · Denominator 104 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 104 |
| Discharge self-care score | 65.06% |
53.69%
11.4 pts better
|
Numerator 54 · Denominator 83 |
| Discharge mobility score | 73.49% |
50.94%
22.5 pts better
|
Numerator 61 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 2.88% |
2.29%
0.6 pts worse
|
Numerator 3 · Denominator 104 · Adjusted rate 3.51% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 4.76% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 1.87% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 107 |
| Staff flu vaccination coverage | 37.74% |
42%
4.3 pts worse
|
Numerator 80 · Denominator 212 |
| Discharge function score | 69.88% |
56.45%
13.4 pts better
|
Numerator 58 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 62 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 27.12% |
25.2%
1.9 pts better
|
Numerator 16 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.8 |
2.3
1.5 pts worse
|
1.9
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 2.5 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.9
0.7 pts better
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.5 · Expected 1.2 · 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 | 4.1% |
4.5%
0.4 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.4% · Q3 3.8% · Q4 4.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
3.3%
2.8 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.6%
1.7 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.3% · Q3 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
25.3%
14.9 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 3.1% · Q3 8.7% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
18.6%
12.4 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.3% · Q3 4.0% · Q4 7.7% · 4Q avg 6.2% · 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 | 25.3% |
15.5%
9.8 pts worse
|
16.3%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
14.1%
5.4 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 10.0% · Q3 4.3% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.1%
1.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.8%
1.9 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.1% |
17.8%
3.7 pts better
|
19.8%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 16.0% · Q3 8.6% · Q4 15.8% · 4Q avg 14.1% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.1%
2.1 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 5.0% · Q3 3.0% · Q4 3.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
75.0%
22.1 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 96.5% · Q3 98.4% · Q4 97.8% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
17.1%
8.2 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 8.2% · Expected 10.3% · 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 | 97.4% |
74.0%
23.4 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
27.0%
4 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 18.8% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-26 · Fire 2023-09-26
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-08 · Fire 2021-10-08
1 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-10-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-12-02
F · Potential for more than minimal harm
2021-10-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-08
F · Potential for more than minimal harm
2021-10-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-06
E · Potential for more than minimal harm
2021-10-08
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 2021-10-06
E · Potential for more than minimal harm
2021-10-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-10-16
E · Potential for more than minimal harm
2021-10-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-10-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-12-05
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 2024-12-27
E · Potential for more than minimal harm
2024-12-05
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-10-31
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-11-01
E · Potential for more than minimal harm
2023-09-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-26
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 2023-10-20
E · Potential for more than minimal harm
2023-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-20
D · Potential for more than minimal harm
2021-10-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-01
Penalties and ownership
What sits behind the stars
Ownership
Fail, Blake
5% Or Greater Direct Ownership Interest · Individual
Gawey, Matthew
5% Or Greater Direct Ownership Interest · Individual
Roberts, Keith
5% Or Greater Direct Ownership Interest · Individual
Brown, Tammy
Operational/Managerial Control · Individual
Fail, Blake
Corporate Officer · Individual
Gawey, Matthew
Corporate Officer · Individual
Luiskutty, Thomas
Operational/Managerial Control · Individual
Neal, Vanessa
Operational/Managerial Control · Individual
Roberts, Keith
Corporate Officer · Individual
Triad Aspen Partners, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Grace Skilled Nursing and Therapy Jenks
Jenks, OK
2-star overall rating with 2-star inspections with $15,646 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Zarrow Pointe
Tulsa, OK
4-star overall rating with 3-star inspections with $8,278 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Ambassador Manor Nursing Center
Tulsa, OK
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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