Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
UNIVERSITY PARK SKILLED NURSING AND THERAPY MEMORY
TAHLEQUAH, OK · 139 certified beds · Last Life Safety survey March 10, 2025
CMS Certification Number 375185 · first certified September 1994
Ownership
Operated by BRIDGES HEALTH · For profit - Partnership
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OK
12 citations — more than 77% of the 283 certified nursing homes in OK. Compared within OK rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (April 2026 to July 2026). Most OK facilities have been surveyed by November 2026. This facility’s last Life Safety survey was March 2025. Facilities in OK are typically surveyed 14–16 months after the last one (median 15), measured over 277 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 12 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in OK, and nationally. Surveyors differ markedly between states, so the OK figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 12 |
| Median facility in OK | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 11, 2022 | 6 |
| November 30, 2023 | 3 |
| March 10, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2023-11-30 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2023-11-30 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2023-11-30 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2022-10-11 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 1 | 2025-03-10 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2022-10-11 |
| K-0222 | 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. | 1 | 2022-10-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-03-10 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 2
- Egress Deficiencies 1
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 10, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (April 9, 2025) |
November 30, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 3, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 3, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 3, 2024) |
October 11, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (November 10, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (November 10, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (November 10, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 10, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 10, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 10, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.