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University Village Retirement Community

8555 South Lewis Avenue, Tulsa, OK 74137 · For profit - Limited Liability company · 80 certified beds · (918) 299-2661 Medicare & Medicaid certified

Call the home — (918) 299-2661 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 15 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2448 E 81st St · (918) 582-8217 · Call to confirm hours
Pharmacy
2488 E 81st St Ste 290 · (918) 927-3340 · Call to confirm hours
Grocery
2019 E 81st St · (918) 894-7146 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
8755 S Lewis Ave · (214) 600-6131

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.1%13.6%15.4%better
Long-stay residents who lose too much weight1.4%3.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.5%2.8%2.0%better
Long-stay residents with depressive symptoms0.0%3.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%4.7%3.3%better
Long-stay residents whose ability to walk worsened22.7%13.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.3%25.7%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.6%95.3%typical
Long-stay residents with pressure ulcers5.0%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control12.0%17.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.6%17.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine97.4%74.1%79.4%better
Short-stay residents rehospitalized after admission21.9%27.3%22.6%typical
Short-stay residents with an outpatient ER visit12.6%16.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.672.311.67worse
Long-stay outpatient ER visits per 1,000 resident days1.732.961.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

36.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 170 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.2%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
71.7%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 71.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 92 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.2%CMS range 29.3–43.951.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.9–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge71.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge71.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge67.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.0–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.94
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.75
Aide hours/ resident / day
4.36
Total nurse hours/ resident / day
0.72
RN hoursweekends
48.1%
Total nursing turnover
30.8%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 68.7 residents a day — about 86% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.36 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.75 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.94 hrs/resident/day on weekends vs 4.53 on weekdays — 13% thinner on weekends. RN hours go from 1.02 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2024-12-05)
5
at the previous standard inspection (2023-09-26)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

  • Potential for harm · E2024-12-05 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure meals were palatable for three (#22, 47 and #54) of three residents who were reviewed for food palatability. The staff engagement coordinator identified 71 residents who received nourishment from the kitchen. Findings: A Food and Nutrition Services policy, revised October 2017, read in part, Food and nutrition services staff will inspect food trays to ensure that the .food appears palatable and attractive, and it is served at a safe and appetizing temperature. On 12/02/24 at 11:05 a.m., a hotbox arrived to the satellite kitchen for the [NAME] hall. Food was removed from the hotbox and placed on the steam table. On 12/02/24 at 11:11 a.m., DA #1 was observed to obtain temperatures of the food. The carrots and green beans were observed to be under holding temperature at 128 degrees Fahrenheit. The food temperatures were not obtained again prior to plating at 11:30 a.m. On 12/02/24 at 11:49 a.m., Resident #22 stated lunch was cold. On 12/02/24 at 2:17 p.m., Resident #54 stated the food was not hot in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure foods were served in a sanitary manner in two of two dining areas. The staff engagement coordinator identified 65 resident who ate food in the dining rooms. Findings: A Food Handling policy statement, revised July 2014, read in part, Food will be .served so that the risk of foodborne illness is minimized. On 12/02/24 at 11:17 a.m., in the satellite kitchen on [NAME] hall, DA #1 was observed to pour ice from a large scoop into multiple glasses and used their gloved hand to guide the ice into the cups. DA #1 was observed to have touched multiple objects prior to guiding the ice with their gloved hand without doffing and sanitizing between. On 12/02/24 at 11:32 a.m., DA #3 was observed to deliver meals to two residents without changing their gloves or sanitizing their hands. DA #3 was observed to touch the counter, residents, and themselves between meals. They placed the drinks on the table by handling the top rim of the cup. On 12/02/24 at 12:05 p.m., a family member of a resident eating in the dining…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-05 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure arbitration agreements contained language which indicated a neutral arbitrator would be utilized and the arbitration would take place at a venue convenient to both parties for three (#20, 38, and #120) of three sampled residents who were reviewed for arbitration agreements. The administrator identified 56 residents who had signed an arbitration agreement. Findings: The admission packet contained the following document which read in part, 8. Arbitration .such Dispute be settled by arbitration, which shall be conducted in Tulsa County, OK in accordance with [company name withheld] Rules of Procedure for Arbitration. The arbitration agreement did not indicate a neutral arbitrator would be utilized. 1. Resident #20 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or Respite Care Agreement revealed the resident signed an arbitration agreement on 02/13/24. 2. Resident #38 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure privacy was provided during urinary catheter care for one (#2) of two sampled residents who were reviewed for urinary catheters. The staff engagement coordinator identified six residents who had urinary catheters. Findings: The Catheter Care, Urinary policy, dated August 2022, read in part, Provide privacy. Resident #2 had diagnoses which included obstructive and reflux uropathy. A physician's order, dated 09/06/24, documented the resident had an indwelling urinary catheter and staff were to provide catheter care every shift. On 12/04/24 at 10:13 a.m., CNA #1 and LPN #1 were observed to provide catheter care to Resident #2 with the resident's roommate in the room in their bed. The privacy curtain was observed to be open and not closed between Resident #2 and their roommate during the catheter care. On 12/04/24 at 2:07 p.m., CNA #1 stated they were to close the privacy curtains during personal care, but had not noticed Resident #2's roommate was in the room. On 12/04/24 at 2:18 p.m., LPN #1 stated they…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure medications were secured in locked medication carts for two (#1 and #2) of seven medication carts observed. The administrator identified 72 residents resided in the facility. Findings: A Storage of Medications policy, dated 10/2024, documented drugs and biologicals used in the facility were stored in locked compartments. On 12/03/24 at 3:08 p.m., medication cart #1 on bluebird hall, outside of room [ROOM NUMBER], was observed to be unlocked. No staff were in view of the cart . On 12/03/24 at 3:17 p.m., medication cart #2, located in the hallway outside of room [ROOM NUMBER], was observed to be unlocked. On 12/03/24 at 3:18 p.m., RN #1 removed a medication from medication cart #1 and went into room [ROOM NUMBER]. The cart remained unlocked. On 12/03/24 at 3:20 p.m., RN #2 was observed to move medication cart #2 to several different rooms, remove medication and enter the room, leaving the cart in the hallway unlocked and unattended…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure records were accurate for one (#21) of five sampled residents who were reviewed for unnecessary medications. The administrator identified 74 residents who resided in the facility. Findings: Resident #21 had diagnoses which included anxiety, depression, and atrial fibrillation. A physician's order, dated 02/19/24, documented staff were to monitor Resident #21 for side effects related to antidepressant medication and to chart in the progress notes if they documented yes that the resident had side effects. A physician's order, dated 02/19/24, documented staff were to monitor Resident #21 for side effects related to anticoagulant medication and to chart in the progress notes if they documented yes that the resident had side effects. A physician's order, dated 10/14/24, documented staff were to monitor Resident #21 for side effects related to antianxiety medication and to chart in the progress notes if they documented yes that the resident had side effects. The October 2024 TAR documented the following side effect…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure arbitration agreements contained language residents and/or resident representatives could rescind the agreement within 30 days of signing and signing the agreement was not a condition of admission for three (#20, 38, and #120) of three sampled residents who were reviewed for arbitration agreements. The administrator identified 56 residents who had signed an arbitration agreement. Findings: 1. Resident #20 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or Respite Care Agreement revealed the resident signed an arbitration agreement on 02/13/24. 2. Resident #38 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or Respite Care Agreement revealed the resident's representative signed an arbitration agreement on 05/28/24. 3. Resident #120 had diagnoses which included unspecified dementia. Review of the Skilled Nursing Facility Agreement revealed the resident signed an arbitration agreement on 12/02/24. Review of the admission…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure catheter tubing was maintained to prevent infection for two (#2 and #27) of two residents who were reviewed for catheter infection prevention. The staff engagement coordinator identified six residents who had catheters. Findings: The Catheter Care, Urinary policy, dated August 2022, read in part, Be sure catheter tubing and drainage bag are kept off the floor. 1. Resident #2 had diagnoses which included obstructive bladder. On 12/02/24 at 3:22 p.m., Resident #2 was observed to be in bed with their catheter tubing on the fall mat. On 12/03/24 at 8:52 a.m., Resident #2 was observed in their wheelchair in their room with their catheter tubing on the floor. On 12/04/25 at 10:13 a.m., Resident #2 was observed in their bed with their catheter bag and tubing on the floor. On 12/04/24 at 10:27 a.m., CNA #1 covered Resident #2, lowered the bed, and placed the fall mat. The resident's catheter tubing was observed to touch the fall mat. 2. Resident #27 had diagnoses which included neurogenic bladder. A…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · tag F0909 — failed to maintain a comfortable temperature — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to inspect a hospice supplied bed for safety prior to use by a resident for one (#1) of three sampled residents reviewed for bed safety. The administrator identified 68 residents resided at the facility. Findings: A facility policy titled Bed Safety and Bed Rails, dated March 2023, read in part, Bed frames, mattresses, and bed rails, are checked for compatibility and size prior to use. Resident #1 had diagnoses which included a history of falling. A progress note, dated 10/21/24 at 10:48 p.m., documented the resident was found on the floor next to the bed. The resident's neck was resting on the bed rails and legs were on the ground. On 10/28/24 at 9:58 a.m., Resident #1's representative stated the incident occurred when the headboard separated from the frame of the bed. On 10/28/24 at 10:26 a.m., Maintenance #1 stated they thought they performed bed inspections quarterly and when something malfunctioned. They stated they did not inspect hospice supplied beds when they were brought into the facility. They stated they did not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to administer oxygen according to physician orders for one (#213) of four sampled residents reviewed for respiratory care. The Resident Census and Conditions of Residents form, dated 09/22/23, documented 11 residents received respiratory treatments. Findings: Res #213 had diagnoses which included COPD. A physician order, dated 09/19/23, documented Res #213 was to receive continuous oxygen at 2 L per minute via nasal cannula. The order documented to titrate oxygen to maintain oxygen saturation above 90%. On 09/21/23 at 10:04 a.m., Res #213 was observed in their room. Their oxygen concentrator was observed to be on and the resident was receiving oxygen via nasal cannula. The oxygen gauge on the concentrator was set above 5 L. On 09/21/23 at 2:17 p.m., Res #213 was observed in the therapy room with a therapy staff member. The resident was observed without portable oxygen on or nearby. On 09/21/23 at 2:20 p.m., RN #2 was asked if the resident had oxygen on, they stated they did not. The RN was asked to check the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 5 citations
  • Potential for harm · E2023-09-26 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure blood pressure medications were administered as ordered for one (#12) of five sampled residents reviewed for medications. The DON identified 31 residents who had blood pressure medications with parameters. Findings: Res #12 had diagnoses which included hypertensive heart disease with heart failure. A physician order, dated 02/20/23, documented lisinopril (ACE inhibitor) 2.5 mg one time a day. Hold if SBP is less than 100; and metoprolol tartrate (beta blocker) 25 mg give 1/2 tablet two times a day. Hold if SBP is less than 100 and heart rate less than 60. The August 2023 MAR documented lisinopril was held four out of 25 opportunities when the SBP was within parameters. It was documented metoprolol was held four out of 49 opportunities with the SBP and heart rate were within parameters. The September 2023 MAR documented lisinopril was held seven out of 31 opportunities when the SBP was within parameters. It was documented metoprolol was held 10 out of 62 opportunities with the SBP and heart rate was within…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure: a. staff were COVID tested during outbreak status per policy and procedure; b. staff wore appropriate PPE for COVID posted isolation precaution rooms per policy and procedure; and c. staff washed their hands with glove changes during wound care per policy and procedure. The DON identified six resident who were on isolation precautions for COVID-19 and two residents who were receiving wound care. Findings: The facility policy, titled Coronavirus Disease (COVID-19) - Testing Staff, documented in part .outbreak is defined as any single new onset of COVID-19 infection in a resident or a single case of infection in any staff . All staff in the unit (or in the facility), regardless of vaccination status, are tested immediately (but not sooner than 24 hours after the exposure) and, if negative, again 48 after the exposure, and a final test 48 hours after second test. If additional cases are identified, testing will continue every 3-7 days (in addition to room restriction and full PPE use for care of exposed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-26 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview. the facility failed to ensure a resident had a physician order to self-administer a nebulizer treatment for one (#16) of one sample resident reviewed for self-administration of medications. The Resident Census and Conditions of Residents report, dated 09/22/23, documented 11 residents who received respiratory treatments. Findings: Res #16 had diagnoses which included COPD. A physician order, dated 05/03/23, documented levalbuterol HCL (breathing treatment) inhalation mobilization solution 1.25 mg/ml. One vial inhale orally via nebulizer three times a day. On 09/21/23 at 1:06 p.m., the resident was observed laying in their bed with a nebulizer treatment being administered through the mask over their nose and mouth. There was no staff present in the room or outside of the resident's door. There was no documentation the resident had a physician's order to self-administer a nebulizer treatment. On 09/21/23 at 1:17 p.m., RN #1 was observed going into the resident's room where they shut the nebulizer treatment off. On 09/21/23 at 1:20…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-26 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to notify the physician of a surgical wound change for one (#212) of one sampled residents reviewed for surgical wounds. The DON identified three residents who had surgical wounds. Findings: Res #212 had diagnoses which included history of right femur fracture and disruption of external surgical wound. A wound specialist note, dated 09/05/23, documented the surgical wound to the right trochanter had been treated for two weeks, and was documented to have steri-strips in place. The note documented the surgical sites to the right lateral upper leg and right inferior lower leg had healed. A skilled nurse note by RN #2, dated 09/07/23 at 11:45 a.m., documented in part .wound dressing changed; sanguineous drainage noted on old dressing, 2/3 of surgical incision skin open, Steri-strips changed . A transfer to hospital summary, dated 09/09/23 at 11:35 a.m., documented the resident was sent to the hospital for neurological evaluation related to new onset left hand weakness. A nurse note, dated 09/09/23 at 10:20 p.m.,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to implement correct hand hygiene infection control for one (#35) of five sampled residents reviewed for wound care. The facility facility wound flow sheet documented 14 residents had wounds. Findings: On 08/20/21 the medical record of resident #35 documented the resident had diagnoses which included pressure induced deep tissue damage to the left heel. An assessment dated [DATE], documented the resident was moderately impaired for daily decision-making and had a stage two pressure ulcer on admission. The care plan, dated 08/20/21, documented the resident had a pressure ulcer on her left heel. The care plan documented the staff were to monitor the resident's nutritional status, complete wound care as ordered, and document weekly wound assessments. The physician orders documented the staff were to apply Santyl to the resident's wound daily. On 10/08/21 at 10:45 a.m., licensed practical nurse (LPN) #1 and #2 were observed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
FAIL, BLAKEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER38%since 07/29/2011
GAWEY, MATTHEWIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER38%since 07/29/2011
ROBERTS, KEITHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER24%since 07/29/2011
TRIAD ASPEN PARTNERS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/15/2025
BROWN, TAMMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/2025
LUISKUTTY, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/03/2022
NEAL, VANESSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/29/2011

CMS files one row per role, so the 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$13.0M
Net patient revenuemost recent cost report
-4.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 20%Medicare 10%Other / private 70%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$554per resident / day
operating cost
$16,832per month
≈ monthly operating cost
$528per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375531. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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