Fort Gibson Care & Rehab Center
205 East Poplar Street, Fort Gibson, OK 74434 · Muskogee County · 66 certified beds · avg 56 residents/day · certified since Jan 1, 1998
Part of chain: MGM HEALTHCARE (27 facilities, chain avg rating 2.3★)
3/5
Health inspection rating (on-site)
1
Serious findings on record
$53,271
Fines, last 3 years
3.59
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jan 15, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 18, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (35)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 15, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 15, 2025 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jan 15, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 15, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 15, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jan 15, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jan 15, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 15, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 20, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 20, 2023 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 4, 2022 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 4, 2022 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Aug 4, 2022 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Aug 4, 2022 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 4, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 4, 2022 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (11 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 16 | 0 | E |
| 2023 | 11 | 0 | E |
| 2025 | 8 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $53,271, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jan 15, 2025 | Fine | $53,271 |
| Jan 15, 2025 | Payment Denial | 7 days from Feb 11, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oklahoma avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.59 | 4.58 | 3.95 | bottom 7% in Oklahoma; bottom 41% in the U.S. |
| Registered Nurse hours | 0.28 | 0.41 | 0.69 | bottom 24% in Oklahoma; bottom 8% in the U.S. |
| Weekend total nurse staffing | 3.06 | 4.16 | 3.50 | bottom 5% in Oklahoma; bottom 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.22 | 0.28 | 0.48 | bottom 37% in Oklahoma; bottom 15% in the U.S. |
| Total nursing staff turnover (%) | 52.7 | 55.5 | 45.8 | top 42% in Oklahoma; bottom 30% in the U.S. |
| RN turnover (%) | 0.0 | 53.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.88, RN 0.30, weekend 3.31. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| JFB Ok Trust | Organization | 5% or Greater Indirect Ownership Interest | 50% | 05/14/2024 |
| Ok SNF Holdings, LLC | Organization | 5% or Greater Direct Ownership Interest | 50% | 05/14/2024 |
| Ok SNF Investments, LLC | Organization | 5% or Greater Direct Ownership Interest | 50% | 05/14/2024 |
| Southeast Ventures Trust | Organization | 5% or Greater Indirect Ownership Interest | 48% | 05/14/2024 |
| Friedman, Naftali | Individual | Corporate Officer | NOT APPLICABLE | 05/14/2024 |
| Smith, Sara | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/14/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Eastgate Village Care & Rehab Center | 5.5 mi | Muskogee, OK | ★★☆☆☆ | 3/5 | |
| York Manor Nursing Home | 6.7 mi | Muskogee, OK | ★☆☆☆☆ | 1/5 | |
| Muskogee Nursing Center | 6.8 mi | Muskogee, OK | ★☆☆☆☆ | 1/5 | |
| Broadway Care & Rehab Center | 6.9 mi | Muskogee, OK | ★☆☆☆☆ | 1/5 | |
| Pleasant Valley Health Care Center | 7.3 mi | Muskogee, OK | ★★★☆☆ | 3/5 | |
| Brentwood Extended Care & Rehab | 9.4 mi | Muskogee, OK | ★☆☆☆☆ | 2/5 | |
| The Springs Skilled Nursing and Therapy | 10.9 mi | Muskogee, OK | ★★★☆☆ | 3/5 | |
| Wagoner Health & Rehab | 13.9 mi | Wagoner, OK | ★★☆☆☆ | 2/5 | |
| University Park Skilled Nursing and Therapy Memory | 17.8 mi | Tahlequah, OK | ★★★★☆ | 4/5 | |
| Sequoyah Pointe Skilled Nursing and Therapy | 17.9 mi | Tahlequah, OK | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 375330.