01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-10 | 5 | 2025-03-10 | 3 |
| Cycle 2 | 2023-11-30 | 8 | 2023-11-30 | 3 |
| Cycle 3 | 2022-10-11 | 15 | 2022-10-11 | 6 |
CMS CCN 3751852026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
University Park Skilled Nursing And Therapy Memory
1201 North Vinita Avenue · Tahlequah, OK 74464 · Cherokee County
Certified beds139CMS provider file
Recent citation rows40current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
40 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-10 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-03-10 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-03-10 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-03-10 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-03-10 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-03-10 · FIREK0347Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Properly provide smoke detection systems in areas open to corridors.
Correction field: Deficient, Provider has date of correction · 2025-04-092025-03-10 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-092025-03-10 · FIREK0362Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2025-04-092025-01-27 · HEALTHF0622Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Correction field: Deficient, Provider has date of correction · 2025-02-11 · complaint2025-01-27 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-02-11 · complaint2025-01-27 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-02-11 · complaint2023-11-30 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2023-12-272023-11-30 · HEALTHF0679Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2023-12-272023-11-30 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Correction field: Deficient, Provider has date of correction · 2023-12-272023-11-30 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-12-272023-11-30 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-12-272023-11-30 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-05-032023-11-30 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-05-032023-11-30 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2024-05-032022-10-11 · FIREE0026Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Correction field: Deficient, Provider has date of correction · 2022-11-102022-10-11 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2022-11-102022-10-11 · HEALTHF0578Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2022-11-102022-10-11 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2022-11-102022-10-11 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2022-11-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BRIDGES EMPLOYEE STOCK OWNERSHIP TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 12/31/2020
- DEROIN, KRISTYIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 04/01/2020
- CRANE, JOANNAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 12/17/2013
- DEROIN, KRISTYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 04/01/2020
- COBLE, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2020
- BRIDGES ESOP, INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/31/2020
- COBLE, WILLIAMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.93per resident day
RN hours0.32per resident day
Weekend nurse hours3.95per resident day
Staff turnover34.7%CMS reported field
06 / LOCAL RECORDS
Open the Tahlequah ledger →