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
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing
LPN hours / resident day
0.74
Licensed practical nurse staffing
Aide hours / resident day
2.88
Nurse aide staffing
Weekend hours
4.05
Weekend nurse staffing
RN turnover
39%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 25.3% |
15.5%
9.8 pts worse
|
16.3%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 97.4% |
74.0%
23.4 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
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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