Cycle 1
Health 2025-01-15 · Fire 2025-01-15
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Gibson, OK
Fort Gibson Care & Rehab Center
3-star overall rating with 3-star inspections with $53,271 in total fines with 8 recent health deficiencies
205 East Poplar Street, Fort Gibson, OK
(918) 478-2456
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mgm Healthcare
Operator or chain grouping
Approved since
1998-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 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
0.33
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.96
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,558
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.11
Baseline 20.58% · Performance 20.46% · Measure score 2.11 · Achievement 2.11 · Improvement 0
Healthcare-associated infections
1.26
Baseline 9.84% · Performance 8.99% · Measure score 1.26 · Achievement 0 · Improvement 1.26
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
2.62
Baseline 3.67 hours · Performance 3.82 hours · Measure score 2.62 · Achievement 2.62 · Improvement 0.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 12.24% · Lower 95% interval 7.29% |
| Discharge to community | 41.73% |
50.57%
8.8 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 30.56% · Lower 95% interval 27.14% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 29 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.99% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 16.67% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 55 |
| Staff flu vaccination coverage | 2.86% |
42%
39.1 pts worse
|
Numerator 2 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.3
0.5 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.9
1.7 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
90.3%
2.1 pts better
|
93.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.2% · Q3 85.0% · Q4 91.5% · 4Q avg 92.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
94.6%
3.4 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
4.5%
0.4 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 4.5% · Q3 0.0% · Q4 4.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.0% |
3.3%
7.7 pts worse
|
11.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 10.0% · Q3 5.3% · Q4 16.3% · 4Q avg 11.0% |
| 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 3.2% · Q3 0.0% · Q4 2.9% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
25.3%
3.6 pts better
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 21.9% · Q3 19.4% · Q4 22.2% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
18.6%
6.4 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.1% · Q3 17.4% · Q4 10.7% · 4Q avg 12.2% · 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 | 5.4% |
15.5%
10.1 pts better
|
16.3%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
14.1%
10.2 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.2% · Q3 3.2% · Q4 2.8% · 4Q avg 3.9% · 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 · 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 | 0.0% |
2.8%
2.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 16.4% |
17.8%
1.4 pts better
|
19.8%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 13.8% · Q3 9.6% · Q4 15.2% · 4Q avg 16.4% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.1%
0.2 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 9.0% · Q3 3.9% · Q4 1.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.3% |
75.0%
21.7 pts worse
|
81.7%
28.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 41.7% · Q3 58.9% · Q4 65.2% · 4Q avg 53.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.0% |
17.1%
3.9 pts worse
|
12.0%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 21.4% · Expected 11.4% · 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% · Q2 0.0% · Q3 0.0% · Q4 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 | 61.3% |
74.0%
12.7 pts worse
|
79.7%
18.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
27.0%
0.1 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 26.2% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
16 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-09-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-09-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-05
C · Minimal harm
2023-09-20
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-04-05
F · Potential for more than minimal harm
2022-08-04
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-09-01
F · Potential for more than minimal harm
2022-08-04
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-09-01
F · Potential for more than minimal harm
2022-08-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-01
E · Potential for more than minimal harm
2022-08-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-09-01
E · Potential for more than minimal harm
2022-08-04
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-09-01
Inspection history
Recent health citations
G · Actual harm
2025-01-15
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 2025-02-18
E · Potential for more than minimal harm
2025-01-15
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 2025-02-18
E · Potential for more than minimal harm
2025-01-15
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 2025-02-18
E · Potential for more than minimal harm
2025-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-15
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-15
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 2025-02-18
E · Potential for more than minimal harm
2023-09-20
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 2023-10-20
E · Potential for more than minimal harm
2023-09-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
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 2023-10-20
D · Potential for more than minimal harm
2023-09-20
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 2023-10-20
D · Potential for more than minimal harm
2023-09-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
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 2023-10-20
D · Potential for more than minimal harm
2023-09-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-20
E · Potential for more than minimal harm
2022-08-04
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 2022-09-01
E · Potential for more than minimal harm
2022-08-04
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 2022-09-01
E · Potential for more than minimal harm
2022-08-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-09-01
E · Potential for more than minimal harm
2022-08-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-01
E · Potential for more than minimal harm
2022-08-04
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-09-01
E · Potential for more than minimal harm
2022-08-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-09-01
E · Potential for more than minimal harm
2022-08-04
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 2022-09-01
E · Potential for more than minimal harm
2022-08-04
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 2022-09-01
E · Potential for more than minimal harm
2022-08-04
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 2022-09-01
E · Potential for more than minimal harm
2022-08-04
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 2022-09-01
E · Potential for more than minimal harm
2022-08-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-08-04
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-08-04
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-08-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-08-04
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 2022-09-01
D · Potential for more than minimal harm
2022-08-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-01
Penalties and ownership
What sits behind the stars
$53,271
2025-01-15
Fine
Fine · fine $53,271
Fine
$0
2025-01-15
Payment Denial
Payment Denial · denial start 2025-02-11 · 7 days
7 day denial
Ownership
Jfb Ok Trust
5% Or Greater Indirect Ownership Interest · Organization
Ok SNF Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Ok SNF Investments, LLC
5% Or Greater Direct Ownership Interest · Organization
Southeast Ventures Trust
5% Or Greater Indirect Ownership Interest · Organization
Friedman, Naftali
Corporate Officer · Individual
Smith, Sara
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Eastgate Village Care & Rehab Center
Muskogee, OK
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
York Manor Nursing Home
Muskogee, OK
1-star overall rating with 1-star inspections with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Muskogee Nursing Center
Muskogee, OK
2-star overall rating with 3-star inspections with $38,066 in total fines with 7 recent health deficiencies
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