McMahon-Tomlinson Nursing Center
2007 NW 52nd Street, Lawton, OK 73505 · Comanche County · 142 certified beds · avg 129 residents/day · certified since Jun 19, 2014
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Dec 16, 2025 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Dec 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 16, 2025 · F-0686
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.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Dec 23, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (23)
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 |
|---|---|---|
| Jun 25, 2026 | E · Potential for harm, repeated | 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. · from a complaint |
| Jun 25, 2026 | 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. · from a complaint |
| Mar 6, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 6, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 16, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Dec 16, 2025 | ▲ G · Actual 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. |
| Mar 11, 2025 | 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. · from a complaint |
| Mar 11, 2025 | 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. · from a complaint |
| Mar 11, 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. · from a complaint |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | D · Potential for harm, one-off | 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. |
| Apr 11, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 3, 2023 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Mar 3, 2023 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (11 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | E |
| 2024 | 11 | 0 | E |
| 2025 | 5 | 2 | G ▲ |
| 2026 | 4 | 0 | E |
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 $6,338.
| Date | Type | Amount / length |
|---|---|---|
| Dec 16, 2025 | Fine | $6,338 |
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) | 4.49 | 4.58 | 3.95 | bottom 47% in Oklahoma; top 23% in the U.S. |
| Registered Nurse hours | 0.20 | 0.41 | 0.69 | bottom 10% in Oklahoma; bottom 3% in the U.S. |
| Weekend total nurse staffing | 4.17 | 4.16 | 3.50 | top 48% in Oklahoma; top 18% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.12 | 0.28 | 0.48 | bottom 5% in Oklahoma; bottom 3% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.5 | 45.8 | — |
| 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 4.05, RN 0.18, weekend 3.77. 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: 2/5 · long-stay residents: 2/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Comanche County Hospital Authority | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/13/1971 |
| Fitch, Natalie | Individual | Corporate Director | NOT APPLICABLE | 01/25/2021 |
| Fitch, Natalie | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2021 |
| Forrest, Stacy | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/09/2022 |
| Forrest, Stacy | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/09/2022 |
| Henry, Mark | Individual | Corporate Director | NOT APPLICABLE | 07/01/2021 |
| Jones, Robert | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/19/2014 |
| Jones, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/19/2014 |
| Kruger, George | Individual | W-2 Managing Employee | NOT APPLICABLE | 08/03/2015 |
| Kruger, George | Individual | Corporate Officer | NOT APPLICABLE | 08/03/2015 |
| Kruger, George | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/03/2015 |
| Legako, Edward | Individual | Corporate Director | NOT APPLICABLE | 05/17/2016 |
| Legako, Edward | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2018 |
| McCall, Charles | Individual | Corporate Director | NOT APPLICABLE | 01/13/2020 |
| McCall, Charles | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2020 |
| Smith, Brent | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/01/2014 |
| Smith, Brent | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2014 |
| Smith, Brent | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2014 |
| Zelbst, John | Individual | Corporate Director | NOT APPLICABLE | 07/01/1997 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "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 |
|---|---|---|---|---|---|
| Montevista Rehabilitation and Skilled Care | 1.3 mi | Lawton, OK | ★★★☆☆ | 3/5 | |
| Willow Park Health Care Center | 1.4 mi | Lawton, OK | ★☆☆☆☆ | 1/5 | |
| Lawton Post Acute & Rehab | 3.0 mi | Lawton, OK | ★☆☆☆☆ | 1/5 | SFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 375562.