Cycle 1
Health 2024-04-11 · Fire 2024-04-11
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lawton, OK
Mcmahon-Tomlinson Nursing Center
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2007 NW 52Nd Street, Lawton, OK
(580) 357-3240
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
113
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-06-19
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
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
11,065
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 23.21% · Performance 26.05% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.30% · Performance 9.21% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.33
Baseline 67.01% · Performance 55.08% · Measure score 2.33 · Achievement 2.10 · Improvement 2.33
Adjusted total nurse staffing
4.93
Baseline 4.24 hours · Performance 4.48 hours · Measure score 4.93 · Achievement 4.93 · Improvement 1.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 16.32% |
10.72%
5.6 pts worse
|
Worse than the National Rate · Eligible stays 530 · Observed rate 19.43% · Lower 95% interval 14.09% |
| Discharge to community | 50.47% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 541 · Observed rate 44.55% · Lower 95% interval 45.7% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.21% |
95.27%
2.9 pts better
|
Numerator 384 · Denominator 391 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 7 · Denominator 391 |
| Discharge self-care score | 51.79% |
53.69%
1.9 pts worse
|
Numerator 116 · Denominator 224 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 64 · Denominator 224 |
| Pressure ulcers or injuries, new or worsened | 1.53% |
2.29%
0.8 pts better
|
Numerator 6 · Denominator 391 · Adjusted rate 1.62% |
| Healthcare-associated infections requiring hospitalization | 9.21% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 369 · Observed rate 10.03% · Lower 95% interval 7.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 80.13% |
42%
38.1 pts better
|
Numerator 125 · Denominator 156 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 112 · Denominator 224 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 167 · Denominator 167 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 160 · Denominator 168 |
| Resident COVID-19 vaccinations up to date | 2.15% |
25.2%
23.1 pts worse
|
Numerator 4 · Denominator 186 |
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 3.7 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.9
0.8 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
90.3%
6.4 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 82.9% · Q3 82.5% · Q4 85.0% · 4Q avg 83.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
94.6%
1 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
4.5%
1.7 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 1.2% · Q4 2.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.7% |
3.3%
9.4 pts worse
|
11.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 12.9% · Q3 13.5% · Q4 13.7% · 4Q avg 12.7% |
| Percentage of long-stay residents who lose too much weight | 10.7% |
3.6%
7.1 pts worse
|
5.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 11.9% · Q3 8.1% · Q4 6.5% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
25.3%
2.2 pts better
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 24.3% · Q3 24.0% · Q4 24.4% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
18.6%
3.2 pts better
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.6% · Q3 14.5% · Q4 17.9% · 4Q avg 15.4% · 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 | 17.3% |
15.5%
1.8 pts worse
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 21.3% · Q3 10.3% · Q4 13.8% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
14.1%
4.9 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 24.3% · Q3 5.8% · Q4 23.9% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.0% |
2.1%
2.9 pts worse
|
1.0%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.8% · Q3 5.3% · Q4 2.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
2.8%
1.1 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.0% · Q3 5.1% · Q4 3.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
17.8%
5 pts worse
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 29.3% · Q3 21.9% · Q4 17.0% · 4Q avg 22.8% |
| 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 2.4% · Q2 3.3% · Q3 4.2% · Q4 2.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
75.0%
16.4 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 92.4% · Q3 92.4% · Q4 88.8% · 4Q avg 91.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
17.1%
0.6 pts better
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 16.9% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.9%
0.4 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.3% · Q3 2.4% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
74.0%
13.3 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
27.0%
2.6 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 26.6% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-03 · Fire 2023-03-03
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-02-07 · Fire 2022-02-07
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-04-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-15
E · Potential for more than minimal harm
2022-02-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-02-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-02-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-03-11
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 2025-03-31
E · Potential for more than minimal harm
2025-03-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
E · Potential for more than minimal harm
2024-04-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
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 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
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 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-11
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 2024-05-15
D · Potential for more than minimal harm
2024-04-11
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 2024-05-15
D · Potential for more than minimal harm
2024-04-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-15
E · Potential for more than minimal harm
2023-03-03
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-04-01
E · Potential for more than minimal harm
2023-03-03
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-01
Penalties and ownership
What sits behind the stars
Ownership
Comanche County Hospital Authority
Operational/Managerial Control · Organization
Fitch, Natalie
Corporate Director · Individual
Fitch, Natalie
Corporate Officer · Individual
Forrest, Stacy
Operational/Managerial Control · Individual
Forrest, Stacy
W-2 Managing Employee · Individual
Henry, Mark
Corporate Director · Individual
Jones, Robert
Operational/Managerial Control · Individual
Jones, Robert
W-2 Managing Employee · Individual
Kruger, George
Operational/Managerial Control · Individual
Kruger, George
Corporate Officer · Individual
Kruger, George
W-2 Managing Employee · Individual
Legako, Edward
Corporate Director · Individual
Legako, Edward
Corporate Officer · Individual
Mccall, Charles
Corporate Director · Individual
Mccall, Charles
Corporate Officer · Individual
Smith, Brent
Operational/Managerial Control · Individual
Smith, Brent
Corporate Officer · Individual
Smith, Brent
W-2 Managing Employee · Individual
Zelbst, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Montevista Rehabilitation And Skilled Care
Lawton, OK
1-star overall rating with 2-star inspections with $27,782 in total fines with 8 recent health deficiencies
#2
Willow Park Health Care Center
Lawton, OK
1-star overall rating with 1-star inspections with $58,171 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Lawton Post Acute & Rehab
Lawton, OK
1-star overall rating with 1-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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