Cycle 1
Health 2025-01-15 · Fire 2025-01-15
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tulsa, OK
The Villages At Southern Hills
5-star overall rating with 5-star inspections
5721 S Lewis Ave, Tulsa, OK
(918) 447-6447
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonegate Senior Living
Operator or chain grouping
Approved since
2011-08-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
1.62
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.66% · Performance 24.35% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4
Baseline 5.71% · Performance 6.64% · Measure score 4 · Achievement 4 · Improvement 0
Total nurse turnover
4.32
Baseline 54.24% · Performance 46.02% · Measure score 4.32 · Achievement 4.32 · Improvement 2.30
Adjusted total nurse staffing
1.69
Baseline 3.24 hours · Performance 3.56 hours · Measure score 1.69 · Achievement 1.69 · Improvement 0.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.72% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 531 · Observed rate 14.5% · Lower 95% interval 10.61% |
| Discharge to community | 53.07% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 509 · Observed rate 45.38% · Lower 95% interval 48.94% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 415 · Denominator 415 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 4 · Denominator 415 |
| Discharge self-care score | 65.33% |
53.69%
11.6 pts better
|
Numerator 130 · Denominator 199 |
| Discharge mobility score | 34.67% |
50.94%
16.3 pts worse
|
Numerator 69 · Denominator 199 |
| Pressure ulcers or injuries, new or worsened | 1.2% |
2.29%
1.1 pts better
|
Numerator 5 · Denominator 415 · Adjusted rate 1.4% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 317 · Observed rate 6.62% · Lower 95% interval 4.51% |
| Staff COVID-19 vaccination coverage | 8.99% |
8.2%
0.8 pts better
|
Numerator 17 · Denominator 189 |
| Staff flu vaccination coverage | 60.32% |
42%
18.3 pts better
|
Numerator 114 · Denominator 189 |
| Discharge function score | 54.27% |
56.45%
2.2 pts worse
|
Numerator 108 · Denominator 199 |
| Transfer of health information to provider | 98.88% |
95.95%
2.9 pts better
|
Numerator 177 · Denominator 179 |
| Transfer of health information to patient | 99.54% |
96.28%
3.3 pts better
|
Numerator 217 · Denominator 218 |
| Resident COVID-19 vaccinations up to date | 20.29% |
25.2%
4.9 pts worse
|
Numerator 42 · Denominator 207 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.3%
9.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| 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 | 10.7% |
3.3%
7.4 pts worse
|
11.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.6% · Q3 15.0% · Q4 4.8% · 4Q avg 10.7% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.6%
3.6 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
25.3%
9.6 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
18.6%
3.3 pts better
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.3% · 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 | 0.0% |
15.5%
15.5 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.9% |
14.1%
11.2 pts better
|
14.9%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.8%
2.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.2% |
17.8%
15.6 pts better
|
19.8%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.1%
2.1 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 6.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
75.0%
23.5 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 97.7% · Q3 99.7% · Q4 99.7% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
17.1%
7.8 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 9.8% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.9%
1.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.4% · Q3 0.4% · Q4 0.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
74.0%
18.5 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
27.0%
4.3 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 24.2% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-26 · Fire 2022-08-26
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-18
E · Potential for more than minimal harm
2022-08-26
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 2022-09-09
E · Potential for more than minimal harm
2022-08-26
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 2022-09-09
Penalties and ownership
What sits behind the stars
Ownership
Preservation Freehold Company
5% Or Greater Indirect Ownership Interest · Organization
Chance, James
Operational/Managerial Control · Individual
Pf Southern Hills SNF Ops, LLC
5% Or Greater Direct Ownership Interest · Organization
Pf Southern Hills SNF Ops, LLC
Operational/Managerial Control · Organization
Sanctuary Ltc, LLC
5% Or Greater Direct Ownership Interest · Organization
Stonegate Senior Living, LP
Operational/Managerial Control · Organization
Sudbeck, Lee
Operational/Managerial Control · Individual
Taylor, John
Operational/Managerial Control · Individual
Umb Bank Na
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Ambassador Manor Nursing Center
Tulsa, OK
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Colonial Manor Nursing Home
Tulsa, OK
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Zarrow Pointe
Tulsa, OK
4-star overall rating with 3-star inspections with $8,278 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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