Cycle 1
Health 2024-07-18 · Fire 2024-07-18
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Atoka, OK
Elmbrook of Atoka
1-star overall rating with 3-star inspections with $6,350 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1526 South Virginia Street, Atoka, OK
(580) 889-2500
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-08-02
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,656
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
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
1.85
Baseline 9.29% · Performance 8.28% · Measure score 1.85 · Achievement 0 · Improvement 1.85
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.24
Baseline 4.06 hours · Performance 4.57 hours · Measure score 5.24 · Achievement 5.24 · Improvement 2.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 13.79% · Lower 95% interval 7.27% |
| Discharge to community | 33.02% |
50.57%
17.5 pts worse
|
Worse than the National Rate · Eligible stays 36 · Observed rate 22.22% · Lower 95% interval 18.8% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.28% |
95.27%
3 pts better
|
Numerator 57 · Denominator 58 |
| Falls with major injury | 3.45% |
0.77%
2.7 pts worse
|
Numerator 2 · Denominator 58 |
| Discharge self-care score | 54.05% |
53.69%
0.4 pts better
|
Numerator 20 · Denominator 37 |
| Discharge mobility score | 37.84% |
50.94%
13.1 pts worse
|
Numerator 14 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 4 · Denominator 58 · Adjusted rate 8.57% |
| Healthcare-associated infections requiring hospitalization | 8.28% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 9.43% · Lower 95% interval 4.88% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 60 |
| Staff flu vaccination coverage | 24.24% |
42%
17.8 pts worse
|
Numerator 16 · Denominator 66 |
| Discharge function score | 51.35% |
56.45%
5.1 pts worse
|
Numerator 19 · Denominator 37 |
| Transfer of health information to provider | 95.45% |
95.95%
0.5 pts worse
|
Numerator 21 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.88% |
25.2%
3.3 pts worse
|
Numerator 7 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.8 |
2.3
2.5 pts worse
|
1.9
2.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.8 · Observed 4.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 8.5 |
2.9
5.6 pts worse
|
1.8
6.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 8.5 · Observed 8.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
90.3%
12.3 pts worse
|
93.4%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 78.4% · Q3 65.0% · Q4 94.9% · 4Q avg 78.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
94.6%
About the same
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
4.5%
0.8 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.4% · Q3 7.5% · Q4 5.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
3.3%
0.3 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.1% · Q3 0.0% · Q4 3.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
3.6%
2.1 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 11.5% · Q4 8.8% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 50.7% |
25.3%
25.4 pts worse
|
19.6%
31.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 47.1% · Q3 48.6% · Q4 57.1% · 4Q avg 50.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 49.5% |
18.6%
30.9 pts worse
|
16.7%
32.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.1% · Q2 50.0% · Q3 52.0% · Q4 40.7% · 4Q avg 49.5% · 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 | 9.8% |
15.5%
5.7 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
14.1%
3.9 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 25.8% · Q3 18.8% · Q4 12.5% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.6% |
2.1%
5.5 pts worse
|
1.0%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.5% · Q3 9.5% · Q4 8.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.8% |
2.8%
4 pts worse
|
1.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 2.7% · Q3 5.4% · Q4 7.7% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.6% |
17.8%
7.2 pts better
|
19.8%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 6.1% · Q3 12.8% · Q4 8.9% · 4Q avg 10.6% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.1%
1.6 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 13.0% · Q3 5.6% · Q4 4.8% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 34.4% |
75.0%
40.6 pts worse
|
81.7%
47.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 35.0% · 4Q avg 34.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.8% |
17.1%
9.7 pts worse
|
12.0%
14.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 28.0% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.0% |
1.9%
8.1 pts worse
|
1.6%
8.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
74.0%
24 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.8% |
27.0%
13.8 pts worse
|
23.9%
16.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 40.8% · Observed 32.0% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-22 · Fire 2023-06-22
3 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-05-16 · Fire 2022-05-16
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-08-15
E · Potential for more than minimal harm
2024-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-15
F · Potential for more than minimal harm
2023-06-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-06-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-11
F · Potential for more than minimal harm
2022-05-16
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 2022-06-10
E · Potential for more than minimal harm
2022-05-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-10
C · Minimal harm
2022-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-18
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 2024-08-09
E · Potential for more than minimal harm
2024-07-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-18
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 2024-08-05
E · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-18
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 2024-08-05
D · Potential for more than minimal harm
2023-06-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-22
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2023-09-08
C · Minimal harm
2023-06-22
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 2023-07-31
F · Potential for more than minimal harm
2022-05-16
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 2022-06-16
E · Potential for more than minimal harm
2022-05-16
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-06-16
E · Potential for more than minimal harm
2022-05-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
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 2022-06-16
Penalties and ownership
What sits behind the stars
$2,117
2023-11-06
Fine
Fine · fine $2,117
Fine
$4,233
2023-10-17
Fine
Fine · fine $4,233
Fine
Ownership
Hardison, Clint
Corporate Officer · Individual
Samples, Robert
W-2 Managing Employee · Individual
Nearby options
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2-star overall rating with 3-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
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