Cycle 1
Health 2025-06-04 · Fire 2025-06-04
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Oklahoma City, OK
South Park East
2-star overall rating with 2-star inspections with abuse icon flag with $23,815 in total fines with 4 recent health deficiencies
225 Southwest 35th Street, Oklahoma City, OK
(405) 631-7444
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Phoenix Healthcare
Operator or chain grouping
Approved since
2004-02-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
59%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,345
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9933
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.09
Baseline 76.67% · Performance 58.06% · Measure score 3.09 · Achievement 1.37 · Improvement 3.09
Adjusted total nurse staffing
4.98
Baseline 4.20 hours · Performance 4.49 hours · Measure score 4.98 · Achievement 4.98 · Improvement 1.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 34.21% |
8.2%
26 pts better
|
Numerator 13 · Denominator 38 |
| Staff flu vaccination coverage | 3.61% |
42%
38.4 pts worse
|
Numerator 3 · Denominator 83 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.9
1.2 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
90.3%
18.7 pts worse
|
93.4%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.4% · Q2 50.0% · Q3 100.0% · Q4 89.5% · 4Q avg 71.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.1% |
94.6%
17.5 pts worse
|
95.5%
18.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 77.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.5%
4.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.3%
3.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
3.6%
5.5 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.1% · Q3 6.9% · Q4 12.9% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
25.3%
8 pts better
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 14.3% · Q3 20.7% · Q4 16.1% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 48.9% |
18.6%
30.3 pts worse
|
16.7%
32.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 47.8% · Q4 51.7% · 4Q avg 48.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.8% |
15.5%
3.7 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
14.1%
0.2 pts worse
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 11.1% · Q3 3.4% · Q4 20.7% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.8%
0.2 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
17.8%
7.1 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 39.2% · Q3 29.7% · Q4 21.7% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.1%
0.8 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.5% · Q3 9.4% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.6% |
75.0%
49.4 pts worse
|
81.7%
56.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 25.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-01-27 · Fire 2023-01-27
12 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-23
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-02-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-02-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-02-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-02-23
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-02-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-02-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-15
F · Potential for more than minimal harm
2024-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-02-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-02-23
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-02-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-02-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-15
F · Potential for more than minimal harm
2023-01-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-01-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-06
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-28
E · Potential for more than minimal harm
2025-09-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-28
D · Potential for more than minimal harm
2025-09-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-28
D · Potential for more than minimal harm
2025-09-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-28
E · Potential for more than minimal harm
2024-02-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-08
E · Potential for more than minimal harm
2024-02-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-23
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2024-04-08
E · Potential for more than minimal harm
2023-01-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-01-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-01-27
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-01-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F803 · Nutrition and Dietary Deficiencies
Health
Ensure 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.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-06
Penalties and ownership
What sits behind the stars
$23,815
2025-09-10
Fine
Fine · fine $23,815
Fine
Ownership
Cain, Larry
5% Or Greater Direct Ownership Interest · Individual
Davis, Dena
Operational/Managerial Control · Individual
Floyd, Shanna
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Hermance, Terry
Operational/Managerial Control · Individual
Phoenix Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Phoenix Healthcare LLC
Operational/Managerial Control · Organization
Phoenix Rehab LLC
Operational/Managerial Control · Organization
Ramming, Lacie
Operational/Managerial Control · Individual
Young, Cathy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Emerald Care Center Southwest LLC
Oklahoma City, OK
1-star overall rating with 1-star inspections with $8,278 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Capitol Hill Skilled Nursing And Therapy
Oklahoma City, OK
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
South Pointe Rehabilitation and Care Center
Oklahoma City, OK
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $202,060 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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