Cycle 1
Health 2024-04-18 · Fire 2024-04-18
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Kingman, AZ
The Gardens Rehab & Care Center
4-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
3131 Western Avenue, Kingman, AZ
(928) 718-0718
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-11-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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 0.72 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,352
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.13% · Performance 21.86% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.64
Baseline 4.32% · Performance 7.64% · Measure score 0.64 · Achievement 0.64 · Improvement 0
Total nurse turnover
0
Baseline 68.89% · Performance 74.24% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.86
Baseline 2.94 hours · Performance 3.61 hours · Measure score 1.86 · Achievement 1.86 · Improvement 1.84
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 182 · Observed rate 9.34% · Lower 95% interval 7.39% |
| Discharge to community | 65.48% |
50.57%
14.9 pts better
|
Better than the National Rate · Eligible stays 186 · Observed rate 63.44% · Lower 95% interval 59.05% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 144 · Denominator 144 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 144 |
| Discharge self-care score | 64.86% |
53.69%
11.2 pts better
|
Numerator 72 · Denominator 111 |
| Discharge mobility score | 53.15% |
50.94%
2.2 pts better
|
Numerator 59 · Denominator 111 |
| Pressure ulcers or injuries, new or worsened | 1.4% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 143 · Adjusted rate 1.66% |
| Healthcare-associated infections requiring hospitalization | 7.64% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 124 · Observed rate 7.26% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 151 |
| Staff flu vaccination coverage | 27.81% |
42%
14.2 pts worse
|
Numerator 42 · Denominator 151 |
| Discharge function score | 74.77% |
56.45%
18.3 pts better
|
Numerator 83 · Denominator 111 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 93.81% |
96.28%
2.5 pts worse
|
Numerator 106 · Denominator 113 |
| Resident COVID-19 vaccinations up to date | 7.04% |
25.2%
18.2 pts worse
|
Numerator 5 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
97.1%
2.5 pts worse
|
93.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 93.9% · Q3 96.8% · Q4 96.8% · 4Q avg 94.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
94.6%
2.7 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.1%
0.5 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
4.2%
0.3 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.3%
5.3 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 11.9% |
20.5%
8.6 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.1% · Q3 10.0% · Q4 10.0% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
11.8%
2.8 pts worse
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 11.5% · Q3 20.0% · Q4 20.0% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 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 | 26.8% |
14.5%
12.3 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
10.8%
6.8 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 21.9% · Q3 13.3% · Q4 13.3% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.8% |
0.9%
4.9 pts worse
|
1.0%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.9% · Q3 3.5% · Q4 6.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.2%
1.9 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 6.5% · Q4 3.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
20.5%
2.5 pts worse
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 25.9% · Q3 14.1% · Q4 21.5% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.8%
2 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.7% · Q3 0.0% · Q4 2.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
91.1%
6.1 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.8% · Q3 96.6% · Q4 96.8% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
10.7%
14.3 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 22.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.1%
0.4 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.8% |
87.3%
3.5 pts better
|
79.7%
11.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
24.6%
2.5 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 23.4% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-02 · Fire 2023-02-02
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-21 · Fire 2021-10-21
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-18
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-05-15
D · Potential for more than minimal harm
2021-10-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-11-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-04
D · Potential for more than minimal harm
2024-11-19
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 2024-12-24
D · Potential for more than minimal harm
2024-11-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-10-15
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 2024-11-21
G · Actual harm
2021-10-21
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 2021-11-12
E · Potential for more than minimal harm
2021-10-21
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 2021-11-12
E · Potential for more than minimal harm
2021-10-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-12-31
D · Potential for more than minimal harm
2021-10-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-11-12
D · Potential for more than minimal harm
2021-10-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-11-12
D · Potential for more than minimal harm
2021-10-21
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2021-11-12
D · Potential for more than minimal harm
2021-10-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-11-12
Penalties and ownership
What sits behind the stars
Ownership
Collins, Jessica
5% Or Greater Direct Ownership Interest · Individual
Collins, Jessica
Operational/Managerial Control · Individual
Collins, Jessica
Corporate Director · Individual
Collins, Jillian
5% Or Greater Direct Ownership Interest · Individual
Collins, Joshua
5% Or Greater Direct Ownership Interest · Individual
Creative Care Inc
5% Or Greater Direct Ownership Interest · Organization
Creative Care Inc
Operational/Managerial Control · Organization
Edwards, Jason
Operational/Managerial Control · Individual
Ernest L Harman Md Zia Way LLC
Operational/Managerial Control · Organization
Harman, Ernest
Operational/Managerial Control · Individual
Lingenfelter, Fred
5% Or Greater Direct Ownership Interest · Individual
Napier, Pierre
Operational/Managerial Control · Individual
Napier, Pierre
Corporate Officer · Individual
Ott, Kristen
Operational/Managerial Control · Individual
Ott, Kristen
Corporate Director · Individual
Overson, Sara
5% Or Greater Direct Ownership Interest · Individual
Terry, Sandra
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
The Lingenfelter Center
Kingman, AZ
2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
#2
Desert Highlands Care Center
Kingman, AZ
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
The Legacy Rehab & Care Center
Bullhead City, AZ
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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