Map showing the location of UNIVERSITY VILLAGE RETIREMENT COMMUNITY in TULSA, Oklahoma
8555 SOUTH LEWIS AVENUE, TULSA, OK, 74137

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • OklahomaAbove 50% of peers282 rated homes · average 2.7★
  • Tulsa CountyAbove 50% of peers33 rated homes · average 2.8★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs OK avg
  • StaffingCan add or remove a star4★+1.4 vs OK avg
  • Quality measuresCan add or remove a star4★+1.1 vs OK avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 43% of peersOK avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 77% of peersOK avg2.6★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 70% of peersOK avg2.9★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.47hrsAbove 87% of peersOK avg3.84Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.84hrsTop 1%OK avg0.34Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better50%Above 66% of peersOK avg56%RN turnover39%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 48% of peersOK avg$21,911Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
15citations
4inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Dec 5, 2024most recent

Citations by monthOct 2021 – Dec 2024

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 5, 20248 citationsCycle 1worst E · no actual harm
  1. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Dec 27, 2024
  2. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Dec 27, 2024
  3. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Dec 27, 2024
  4. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 27, 2024
  5. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Dec 27, 2024
  6. F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.AdministrationD · isolatedCorrected Dec 27, 2024
  7. F848Provide a neutral and fair arbitration process and agree to arbitrator and venue.AdministrationE · patternCorrected Dec 27, 2024
  8. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Dec 27, 2024
Oct 31, 20241 citationCycle 2worst D · no actual harm
  1. F909Regularly 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.EnvironmentalD · isolatedCorrected Nov 1, 2024
Sep 26, 20235 citationsCycle 2worst E · no actual harm
  1. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Oct 20, 2023
  2. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 20, 2023
  3. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Oct 20, 2023
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Oct 20, 2023
  5. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 31, 2023
Oct 8, 20211 citationCycle 3worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 1, 2021

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.47hrsAbove 87% of peers+0.63 vs OK avg
  • Registered nursesRN hours only0.84hrsTop 1%+0.50 vs OK avg
  • Licensed practical nursesLPN hours0.74hrs
  • Nurse aidesCNA hours2.88hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.05hrs
  • Oklahoma average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better50%Above 66% of peersOK avg 56%
  • RN turnoverRegistered nurses only39%Not ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy80 certified beds · ~68 residents a day85%Above 88% of peersOK avg 64%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $21,911OK avg in fines
Above only 48% of peersFewer fines than 48% of rated homes in Oklahoma

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Oklahoma facilities average 1.3 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Blake Fail
  • Matthew Gawey
  • Keith Roberts
Operational or managerial control
  • Triad Aspen Partners, LLC
  • Tammy Brown
  • Thomas Luiskutty
  • Vanessa Neal
Corporate officers
  • Blake Fail
  • Matthew Gawey
  • Keith Roberts

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 375531 · 8555 SOUTH LEWIS AVENUE, TULSA, OK, 74137.
  • Percentiles compare this facility with every rated nursing home in Oklahoma and Tulsa County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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