Cycle 1
Health 2024-09-13 · Fire 2024-09-13
8 health deficiencies
Top issue: Resident Rights (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Sapulpa, OK
The Gardens
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1165 South Brenner Road, Sapulpa, OK
(918) 224-0600
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Phoenix Healthcare
Operator or chain grouping
Approved since
2002-02-25
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
0.34
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
66%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,499
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.26% · Performance 23.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.21
Baseline 8.14% · Performance 7.92% · Measure score 0.21 · Achievement 0 · Improvement 0.21
Total nurse turnover
3.77
Performance 48.28% · Measure score 3.77 · Achievement 3.77 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.65
Baseline 4.25 hours · Performance 4.97 hours · Measure score 6.65 · Achievement 6.65 · Improvement 4.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.82% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 15.29% · Lower 95% interval 8.46% |
| Discharge to community | 55.16% |
50.57%
4.6 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 49.23% · Lower 95% interval 42.1% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.57% |
95.27%
3.3 pts better
|
Numerator 69 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 35 · Denominator 55 |
| Discharge mobility score | 34.55% |
50.94%
16.4 pts worse
|
Numerator 19 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 70 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 5.07% |
| Staff COVID-19 vaccination coverage | 21.74% |
8.2%
13.5 pts better
|
Numerator 20 · Denominator 92 |
| Staff flu vaccination coverage | 20% |
42%
22 pts worse
|
Numerator 17 · Denominator 85 |
| Discharge function score | 47.27% |
56.45%
9.2 pts worse
|
Numerator 26 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 4 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
2.3
1.2 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 5.2 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.9
0.5 pts better
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
90.3%
9.2 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.0% |
94.6%
10.6 pts worse
|
95.5%
11.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
4.5%
1.4 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 2.1% · Q4 5.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
3.3%
1.5 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 0.0% · Q4 2.3% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
3.6%
1.3 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.3% · Q3 3.1% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
25.3%
11.1 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 16.2% · Q3 14.3% · Q4 15.0% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
18.6%
11.2 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.3% · Q3 7.7% · Q4 6.5% · 4Q avg 7.4% · 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 | 20.3% |
15.5%
4.8 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
14.1%
6.1 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 9.1% · Q3 6.2% · Q4 2.6% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.1%
1.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.8%
0.6 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 2.4% · Q3 2.3% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
17.8%
0.3 pts worse
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 17.4% · Q3 11.0% · Q4 9.7% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.1%
2.5 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 10.2% · Q3 8.3% · Q4 9.1% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
75.0%
24.4 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
17.1%
4.4 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 13.0% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.6% |
74.0%
3.6 pts better
|
79.7%
2.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
27.0%
0.1 pts better
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 27.5% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-19 · Fire 2023-07-19
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-01-12 · Fire 2022-01-12
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-13
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-10-14
F · Potential for more than minimal harm
2023-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-31
E · Potential for more than minimal harm
2022-01-12
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 2022-03-01
E · Potential for more than minimal harm
2022-01-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-03-01
C · Minimal harm
2022-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-13
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-13
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-13
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-13
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-10-22
D · Potential for more than minimal harm
2023-07-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-16
E · Potential for more than minimal harm
2022-01-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-01
E · Potential for more than minimal harm
2022-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-01
E · Potential for more than minimal harm
2022-01-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-03-01
E · Potential for more than minimal harm
2022-01-12
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-03-01
E · Potential for more than minimal harm
2022-01-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-03-01
E · Potential for more than minimal harm
2022-01-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-12
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-12
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-01
Penalties and ownership
What sits behind the stars
Ownership
Barnes, Candace
Operational/Managerial Control · Individual
Beckner, Suzanne
Operational/Managerial Control · Individual
Cain, Larry
5% Or Greater Direct Ownership Interest · Individual
Floyd, Shanna
Operational/Managerial Control · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Lade, Arvid
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
Young, Cathy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Arbor Village
Sapulpa, OK
3-star overall rating with 3-star inspections with 6 recent health deficiencies
#2
Beacon Ridge
Sapulpa, OK
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Glenwood Skilled Nursing And Therapy
Glenpool, OK
3-star overall rating with 3-star inspections with $7,713 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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