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UNIVERSITY PARK SKILLED NURSING AND THERAPY MEMORY Inspection Report, Violations & Safety Grade (TAHLEQUAH, Oklahoma)

1201 NORTH VINITA AVENUE, TAHLEQUAH, Oklahoma 74464

Phone: 9184566181

CMS Overall:4/5

Overview & Bed Count

Certified Beds
139
Avg Residents/Day
47.1
Ownership
For profit - Partnership
Provider Type
Medicare and Medicaid
County
Cherokee
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health4/5
Staffing4/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityOklahoma AvgDifference
RN Hours per Resident per Day0.440.34+0.11
Total Nurse Hours per Resident per Day3.813.82-0.00
CMS Staffing Rating4/52.7/5-
Nursing Staff Turnover41.5%55.4%-

Health Citation History

28 health citations on record

DateCategoryDescriptionSeverity
2025-03-10Nursing and Physician Services DeficienciesObserve each nurse aide's job performance and give regular training.E – Moderate Harm Potential
2025-03-10Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2025-03-10Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2025-03-10Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.D – Moderate Harm Potential
2025-03-10Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2025-01-27Resident Rights DeficienciesNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.D – Moderate Harm Potential
2025-01-27Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2025-01-27Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2023-11-30Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-11-30Quality of Life and Care DeficienciesProvide activities to meet all resident's needs.E – Moderate Harm Potential
2023-11-30Pharmacy Service DeficienciesEnsure 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.E – Moderate Harm Potential
2023-11-30Resident Rights DeficienciesHonor 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.D – Moderate Harm Potential
2023-11-30Quality of Life and Care DeficienciesProvide 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.D – Moderate Harm Potential
2022-10-11Resident Rights DeficienciesHonor 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.E – Moderate Harm Potential
2022-10-11Resident Rights DeficienciesHonor 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.E – Moderate Harm Potential
2022-10-11Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.E – Moderate Harm Potential
2022-10-11Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.E – Moderate Harm Potential
2022-10-11Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2022-10-11Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.E – Moderate Harm Potential
2022-10-11Nutrition and Dietary DeficienciesEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.E – Moderate Harm Potential
2022-10-11Nutrition and Dietary DeficienciesEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.E – Moderate Harm Potential
2022-10-11Nutrition and Dietary DeficienciesEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.E – Moderate Harm Potential
2022-10-11Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2022-10-11Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2022-10-11Resident Assessment and Care Planning DeficienciesPASARR screening for Mental disorders or Intellectual DisabilitiesD – Moderate Harm Potential
2022-10-11Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2022-10-11Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2022-10-11Environmental DeficienciesMake sure that a working call system is available in each resident's bathroom and bathing area.D – Moderate Harm Potential

Fire Safety Citation History

12 fire safety citations on record

DateCategoryDescriptionSeverity
2025-03-10Smoke DeficienciesProperly provide smoke detection systems in areas open to corridors.F – Moderate Harm Potential
2025-03-10Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2025-03-10Smoke DeficienciesEnsure that corridors are separated from use areas by walls constructed to limit the passage of smoke.E – Moderate Harm Potential
2023-11-30Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.F – Moderate Harm Potential
2023-11-30Smoke DeficienciesProvide properly protected cooking facilities.E – Moderate Harm Potential
2023-11-30Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2022-10-11Emergency Preparedness DeficienciesEstablish roles under a Waiver declared by secretary.F – Moderate Harm Potential
2022-10-11Emergency Preparedness DeficienciesEstablish emergency prep training and testing.F – Moderate Harm Potential
2022-10-11Egress DeficienciesAdd 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.E – Moderate Harm Potential
2022-10-11Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2022-10-11Smoke DeficienciesProvide properly protected cooking facilities.E – Moderate Harm Potential
2022-10-11Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.C – Minimal Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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