Southern Hills Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

54.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 54.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 106 beds and averages 77.6 residents a day — about 73% occupied, or roughly 28 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.90 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.68 hrs/resident/day on weekends vs 3.92 on weekdays — 6% thinner on weekends. RN hours go from 0.19 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 85% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · J2025-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  1. On 04/21/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to supervise residents with exit seeking behaviors. On 04/14/25 Resident #14 was observed to leave the courtyard by a resident, from an unlocked gate, staff were notified and were able to redirect Resident #14 back into the building. Based on record review and interview, the facility failed to provide supervision for 1 (#14) of 1 sampled resident reviewed for exit seeking behaviors. The DON identified 66 residents resided at the facility. Findings: An elopement evaluation, dated 03/27/25, showed Resident #14 was at risk for elopement. The evaluation showed Resident #14 wandered aimlessly and the behavior was likely to affect the safety or well-being of self or others. A care plan, dated 03/28/25, showed Resident #14 liked to go to the courtyard and staff were educated to keep an eye as they passed by. An un-witnessed fall incident report, dated 03/29/25, showed Resident #14 had a history of wandering. An elopement evaluation, dated 04/04/25, showed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-10 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2 hour required time frame for 2 (#2 and #5) of 3 sampled residents reviewed for abuse.The DON identified 67 residents resided in the facility.Findings: A facility policy titled ABUSE PREVENTION POLICY & PROCEDURE, revised 05/23/17, read in part, Any allegation of abuse is reported immediately to the state agency and to all other agencies as required, per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. Refer to State, Federal and Elder Justice Act guidelines.1. An undated face sheet showed Res #2 had diagnoses which included multiple sclerosis, age related osteoporosis, contractures, and muscle wasting and atrophy.Res #2's quarterly assessment, dated 04/21/25, showed the residents cognition was intact and a BIM score of 15.An OSDH incident report, with an incident date of 06/06/25, showed on 06/09/25 at 12:45…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 2 (#2 and #5) of 3 sampled residents reviewed for abuse.The DON identified 67 residents resided in the facility.Findings: A facility policy titled ABUSE PREVENTION POLICY & PROCEDURE, revised 05/23/17, read in part, Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner as detailed below. An incident of abuse incident of abuse must be reported to the charge nurse who will examine the resident, document findings in the clinical records an immediately initiate the Investigation protocol.1. An undated face sheet showed Res #2 had diagnoses which included multiple sclerosis, age related osteoporosis, contractures, and muscle wasting and atrophy.Res #2's quarterly assessment, dated 04/21/25, showed the residents cognition was intact with a BIM score of 15.An OSDH incident report, with an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-11-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and interview, the facility failed to ensure infection control practices were followed during dining services. The administrator identified 62 residents received meals from the kitchen. Findings: On 11/19/24 at 12:00 p.m., rehabilitative service manager #1 and restorative aide #1 were observed passing hall trays. They were not observed to sanitize their hands after delivering resident lunch trays. On 11/19/24 at 12:07 p.m., rehabilitative service manager #1 stated they sanitize their hands after every second tray. On 11/19/24 at 12:10 p.m., restorative aide #1 stated they sanitize their hands after every third tray. On 11/26/24 at 1:30 p.m., the administrator stated they should sanitize their hands after delivering every tray.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-26 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide information to formulate an advance directive for three (#33, #38, and #41) of three sampled residents who were reviewed for advance directives. The administrator identified 66 residents resided in the facility. Findings: The undated document, Residents' Rights Regarding Treatment and Advance Directives, read in part, It is the policy of this facility to support and facilitate a residents right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. 1. Resident #33 was admitted to the facility on [DATE]. No acknowledgement for an advance directive was in the resident's medical record. 2. Resident #38 was admitted to the facility on [DATE]. No acknowledgement for an advance directive was in the resident's medical record. 3. Resident #41 was admitted to the facility on [DATE]. No acknowledgement for an advance directive was in the resident's medical record. On 11/20/24 at 3:00 p.m., the social…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-11-01 · tag F0838 — failed to assess facility resources and resident needs — widespread
  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.
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a facility assessment was completed annually. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: The Facility Assessment policy, dated October 2018, read in part, .A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations . On 10/24/23, the administrator provided a copy of the facility assessment dated [DATE] through 09/08/22. They stated they were checking to see if the former administrator had completed a more recent facility assessment. On 10/27/23 at 3:24 p.m., the administrator stated the facility assessment, dated 09/09/21 through 09/08/22, was the most recent assessment they had. They stated the facility assessment should have been completed annually.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-01 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure the care plan was implemented related to smoking for one (#13) of one sampled residents whose care plans were reviewed for smoking. The DON identified 20 residents who smoked. Findings: The Care Plans, Comprehensive Person Centered policy, dated September 2013, read in parts, .A comprehensive .care plan .is implemented for each resident . The Smoking Policy - Residents, dated July 2017, read in part, .A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change .and as determined by staff . Resident #13 had diagnoses which included hypertension. A Smoking Assessment, dated 02/24/23, documented the resident was safe to smoke with supervision. Review of the clinical record did not reveal any smoking assessments had been completed after 02/24/23. The Care Plan, dated 08/05/23, documented the resident smoked and a smoking evaluation was to be completed per the facility policy. On 10/27/23 at 1:49 p.m., the ADON stated smoking assessments were to be completed quarterly. They stated the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure skin assessments were conducted for one (#34) of three sampled residents who were reviewed for pressure ulcers. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/24/23, documented 64 residents resided in the facility. Findings: The Prevention of Pressure Injuries policy, dated April 2020, read in parts, .Assess the resident on admission .for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition .Conduct a comprehensive skin assessment .with each risk assessment . Resident #34 had diagnoses which included atrial fibrillation. The Wound - Weekly Observation Tool, dated 04/13/23, documented a stage three pressure ulcer to the sacrum had resolved. The Care Plan, dated 07/25/23, documented the resident had a history of a healed stage four pressure ulcer to the left buttocks with a documented intervention to conduct weekly skin assessments. The significant change assessment, dated 07/25/23, documented the resident was cognitively intact…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-01 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure behavior and side effect monitoring was conducted for one (#45) of five residents who were reviewed for unnecessary medications. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: Resident #45 had diagnoses which included pain, depressive disorder, insomnia, and chronic embolism and thrombosis. The MAR/TAR, dated 08/16/23 through 08/31/23, documented the resident was administered Prozac (an antidepressant) 10mg daily, Ramelteon (a hypnotic medication) 8mg at bedtime, Eliquis (a blood thinner/anticoagulant medication) 2.5mg twice daily, and Oxycodone (an opiate pain medication) 5mg every four hours as needed. The MAR/TAR, dated 08/16/23 through 08/31/23 did not contain documentation of side effect and/or behavior monitoring for Prozac, Ramelteon, Eliquis, or Oxycodone. The quarterly assessment, dated 08/22/23, documented the resident had received an antidepressant, hypnotic, and anticoagulant medication seven of seven days during the look back…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-01 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac fever caused by Legionella Bacteria and have an effective and consistent infection surveillance program. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: An undated facility policy, titled Legionella Surveillance and Detection, read in parts, .The water management program includes the following elements .A detailed description and diagram of the water system in the facility .The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria . On 11/01/23 at 11:35 a.m., the DON stated the facility did not have a detailed description and diagram of the facility water supply and had not identified areas in the water system that could encourage the growth and spread of Legionella. The DON stated that tracking and trending of infectious diseases was not occurring in the facility until they took the DON…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-01 · tag F0881 — failed to use antibiotics responsibly — pattern
  Implement a program that monitors antibiotic use.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview, the facility failed to implement an antibiotic stewardship program. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility. Findings: An undated facility policy, titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, read in part, .As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee .All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form . On 10/31/23 at 10:40 a.m., the infection preventionist/ADON stated I should ask the DON what criteria the facility used for antibiotic stewardship. On 11/01/23 at 11:35 a.m., the DON stated they were not utilizing a facility approved antibiotic tracking form for antibiotic regimens. The DON stated they were not sure if the infection preventionist/ADON was reviewing antibiotic use.

  Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$15,766 in federal fines across 1 penalty.

• $15,766 — penalty dated 2025-05-15

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 35 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $720K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK