Cycle 1
Health 2025-05-06 · Fire 2025-05-06
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Hugo, OK
Elmbrook Of Hugo
2-star overall rating with 2-star inspections with abuse icon flag with $49,641 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1200 West Finley, Hugo, OK
(580) 326-8383
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elmbrook Management Company
Operator or chain grouping
Approved since
2000-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 4 health / 3 staffing / 2 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
1.16
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.39
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
5.07
CMS adjusted total nurse staffing hours
Case-mix index
1.03
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,641
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.09
Composite VBP score used to determine payment impact.
Payment multiplier
1.0101
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Baseline 21.18% · Performance 19.71% · Measure score 3.71 · Achievement 3.71 · Improvement 3.04
Healthcare-associated infections
6.68
Baseline 7.71% · Performance 5.84% · Measure score 6.68 · Achievement 6.68 · Improvement 6.40
Total nurse turnover
7.42
Baseline 50.91% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 6.24
Adjusted total nurse staffing
4.22
Baseline 4.25 hours · Performance 4.28 hours · Measure score 4.22 · Achievement 4.22 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.83% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 7.55% · Lower 95% interval 6.04% |
| Discharge to community | 52.51% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 48.42% · Lower 95% interval 44.74% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.34% |
95.27%
0.9 pts worse
|
Numerator 50 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 47.62% |
53.69%
6.1 pts worse
|
Numerator 20 · Denominator 42 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 21 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.84% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 0% · Lower 95% interval 2.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 37.35% |
42%
4.6 pts worse
|
Numerator 31 · Denominator 83 |
| Discharge function score | 54.76% |
56.45%
1.7 pts worse
|
Numerator 23 · Denominator 42 |
| Transfer of health information to provider | 96.97% |
95.95%
1 pts better
|
Numerator 32 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 6 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 1.9 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.9
0.7 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 2.6 · Expected 1.2 · 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 98.1% · 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 | 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 | 3.0% |
4.5%
1.5 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 3.9% · Q4 4.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
3.3%
2.7 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
3.6%
2 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 3.4% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
25.3%
1.5 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 34.4% · Q3 23.3% · Q4 20.7% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
18.6%
4.3 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 17.9% · Q3 26.9% · Q4 25.0% · 4Q avg 22.9% · 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 | 26.4% |
15.5%
10.9 pts worse
|
16.3%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.5% · Q2 19.9% · Q4 17.0% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.0% |
14.1%
8.9 pts worse
|
14.9%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 16.1% · Q3 24.1% · Q4 25.9% · 4Q avg 23.0% · 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 · 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 with a urinary tract infection | 2.5% |
2.8%
0.3 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 5.9% · Q4 2.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
17.8%
2.5 pts worse
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 21.0% · Q3 26.0% · Q4 16.1% · 4Q avg 20.3% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
5.1%
4.4 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
75.0%
11.5 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 80.0% · Q3 83.3% · Q4 96.2% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
17.1%
9.7 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.0% · Expected 10.5% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
74.0%
17.4 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
27.0%
3.2 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 18.6% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-15 · Fire 2022-07-15
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-19
E · Potential for more than minimal harm
2022-07-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-15
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-08-26
E · Potential for more than minimal harm
2022-07-15
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 2022-08-24
E · Potential for more than minimal harm
2022-07-15
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-24
C · Minimal harm
2022-07-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-24
Inspection history
Recent health citations
J · Immediate jeopardy
2025-05-06
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 2025-03-05
D · Potential for more than minimal harm
2025-05-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-05-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-07
J · Immediate jeopardy
2024-06-21
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-06-12
G · Actual harm
2024-06-21
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 2024-07-01
D · Potential for more than minimal harm
2024-06-21
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 2024-07-01
D · Potential for more than minimal harm
2024-06-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-01
F · Potential for more than minimal harm
2023-12-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-09
E · Potential for more than minimal harm
2023-12-07
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
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 2024-01-11
D · Potential for more than minimal harm
2023-12-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-10
D · Potential for more than minimal harm
2023-12-07
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 2023-12-10
K · Immediate jeopardy
2023-04-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-25
F · Potential for more than minimal harm
2022-07-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-15
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 2022-08-24
Penalties and ownership
What sits behind the stars
$15,147
2025-05-06
Fine
Fine · fine $15,147
Fine
$14,433
2024-06-21
Fine
Fine · fine $14,433
Fine
$20,061
2023-04-21
Fine
Fine · fine $20,061
Fine
Ownership
Coble, Tom
5% Or Greater Direct Ownership Interest · Individual
Coble, Tom
Contracted Managing Employee · Individual
Needham, Alandra
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Homestead of Hugo
Hugo, OK
1-star overall rating with 1-star inspections with $38,841 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Antlers Manor
Antlers, OK
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Choctaw Nation Nursing Home
Antlers, OK
1-star overall rating with 1-star inspections with $38,532 in total fines with 22 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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