Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elmbrook Of Hugo during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was verbally abused by a certified medication aide, resulting in visible distress and crying. Witness statements and video review confirmed the aide's raised voice caused the resident's reaction. The incident was reported to the state, and the resident's family was notified.
A resident with dementia and peripheral vascular disease was incorrectly assessed as having an indwelling catheter, despite no catheter being present or ordered during the assessment period. The error was identified through observation, record review, and staff interview, revealing the assessment was inaccurately coded.
A resident with multiple medical diagnoses was assessed as safe to smoke independently, but their care plan did not document their smoking status. The ADON confirmed that smoking should have been included in the care plan, and noted that several residents in the facility smoked.
A resident with heart failure and COPD was observed using oxygen equipment that was not labeled with the date, contrary to the care plan which required weekly changes and proper dating of tubing and humidifier bottles. The ADON confirmed the care plan was not followed.
A resident with full code status experienced a critical drop in oxygen saturation, but CPR was not initiated due to staff's failure to verify the resident's code status. The resident passed away without receiving CPR, as LPNs incorrectly believed the resident was a DNR. The incident led to disciplinary actions, including termination for one LPN.
A resident with congestive heart failure and pneumonia experienced a significant drop in oxygen saturation, but the LPN failed to notify the physician or initiate emergency procedures. The resident, who was a full code, was mistakenly believed to be a DNR by the LPN, leading to a lack of appropriate response. The resident was later found without vital signs, and the LPN admitted they would have acted differently had they known the correct code status.
A facility failed to offer a resident the choice to formulate an advance directive within the required timeframe. Despite having a policy in place, the resident's medical record lacked an advance directive acknowledgment, even though the resident was documented as a full code. The DON was unable to locate the necessary documentation.
A resident with congestive heart failure, pneumonia, and sleep apnea did not receive care according to physician's orders. The resident was given oxygen at higher rates than prescribed, lacked a CPAP order, and had a non-functional CPAP. When the resident's oxygen saturation dropped, the LPN did not initiate CPR or contact emergency services, mistakenly believing the resident was a DNR. The DON admitted the CPAP order was missed and that nurses should have followed the physician's orders.
Failure to Prevent Verbal Abuse of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of neurocognitive disorder with Lewy body, diabetes, and major depressive disorder was subjected to verbal abuse by a certified medication aide. The incident was witnessed and documented, with statements indicating that the aide's raised tone of voice caused the resident to become upset and cry. The resident was observed in a distressed state, speaking loudly and tearfully in a common area, expressing confusion and a need for help. The resident's assessment indicated severe impairment in daily decision-making and a low BIMS score, and the resident was receiving antipsychotic, antianxiety, and antidepressant medications at the time. The facility's policy required immediate suspension of any employee accused of abuse pending investigation. The incident was reported to the state health department, and the resident's family was notified the same evening. The administrator reviewed video footage of the incident and, based on the staff member's facial expressions and gestures, determined that verbal abuse had occurred. The facility had reported six allegations of abuse to the state health department within the past year.
Inaccurate Assessment of Indwelling Catheter Status
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments regarding indwelling catheters for one resident. During an observation, the resident was found in bed with a bedside commode and no indwelling catheter present. The resident's face sheet indicated diagnoses of dementia and peripheral vascular disease, and a quarterly assessment documented the presence of an indwelling catheter. However, a review of the medical record for the assessment period revealed no physician order for a catheter, and the resident stated they did not have one and could not recall ever having one. The minimum data set coordinator later confirmed that the resident did not have an indwelling catheter during the assessment period and that the assessment had been coded in error.
Failure to Care Plan for Resident Smoking Needs
Penalty
Summary
The facility failed to implement a care plan addressing the smoking needs of a resident who was admitted with diagnoses including hypertensive heart disease, chronic atrial fibrillation, and anxiety disorder. Although a smoking assessment determined the resident was safe to smoke independently, the resident's care plan did not document that the resident smoked. The Assistant Director of Nursing (ADON) confirmed that smoking should have been included in the care plan, and also reported that five residents in the facility smoked. This omission was identified through record review and staff interview.
Failure to Follow Respiratory Care Plan for Oxygen Tubing and Humidifier Labeling
Penalty
Summary
The facility failed to follow the established plan of care for a resident requiring respiratory care. During observations on two separate days, the resident was seen using oxygen at 3 liters per minute, but the oxygen tubing and humidifier bottle were not labeled with the date as required. The resident's care plan specified that oxygen tubing should be changed weekly, labeled with the correct date, and stored properly with the date indicated. The Assistant Director of Nursing confirmed that the care plan should have been followed. The resident had medical diagnoses including heart failure and chronic obstructive pulmonary disease.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) to a resident who was designated as full code status, leading to a deficiency. The resident, who had diagnoses including congestive heart failure, pneumonia, and dyspnea, experienced a significant drop in oxygen saturation levels. Despite the resident's full code status, CPR was not initiated, and emergency services were not contacted. The resident's oxygen saturation dropped to critically low levels, and the resident eventually passed away without receiving CPR. The deficiency was exacerbated by the lack of awareness and verification of the resident's code status by the nursing staff. LPN #1, who was responsible for the resident's care, was not aware of the process to check or verify a resident's code status and was incorrectly informed by another nurse that the resident was a Do Not Resuscitate (DNR). This misinformation led to a failure to initiate CPR when the resident's condition deteriorated. Additionally, the LPN was unaware of the standard requirement to start CPR on residents with unknown code status until EMS or a provider stopped CPR. Multiple staff members, including CNAs, were involved in the situation and were misinformed about the resident's code status. The CNAs were told by LPNs that the resident was a DNR, which was later discovered to be incorrect. The failure to verify the resident's code status and initiate life-saving measures resulted in disciplinary actions for the involved staff, including termination for LPN #1. The facility's documentation also lacked an advance directive acknowledgment for the resident, further complicating the situation.
Removal Plan
- Staff were in-serviced on CPR status, DNR code status policy and procedures.
- Code status identification policy and procedures were included in all new hire packets, with in-person training.
- Code status identification was observed at each room/name plates on the memory care unit.
- The Activity Director was in-serviced regarding code status and CPR.
- LPN #3 was in-serviced regarding code status and CPR.
- Code status identification was observed at room/name plates in the long term care halls.
- RN #2 reviewed the in-service documentation.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition, which led to a deficiency in care. The resident, who had diagnoses including congestive heart failure, pneumonia, and dyspnea, was observed by an LPN to have a significantly low oxygen saturation level of 55% while on 3 liters of oxygen. Despite attempts to increase the oxygen flow and use a CPaP machine, the resident's oxygen saturation did not improve and eventually dropped to 35%. The LPN did not contact emergency services or the physician during this time, and the resident was later found without vital signs. A CNA reported that the LPN believed the resident was a DNR, which was incorrect as the resident was a full code. The CNA had questioned the LPN about the resident's code status multiple times, but the LPN did not initiate CPR or contact emergency services when the resident's condition deteriorated. The LPN later acknowledged that they would have sent the resident to the hospital had they known the correct code status. An RN confirmed that the LPN should have contacted the resident's doctor when the condition changed.
Failure to Offer Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that a resident was offered the choice to formulate an advance directive. The facility's policy requires that within 72 hours of admission, the social services director or designee must inquire about the existence of any written advance directives and provide written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive. However, for one resident with diagnoses including congestive heart failure and pneumonia, there was no advance directive acknowledgment found in the medical record. Despite a physician's order and care plan indicating the resident was a full code, the Director of Nursing reported being unable to locate the advance directive acknowledgment for this resident.
Failure to Follow Physician's Orders and Ensure Equipment Functionality
Penalty
Summary
The facility failed to follow physician's orders and ensure proper equipment functionality for a resident with oxygen and CPAP needs. The resident, diagnosed with congestive heart failure, pneumonia, and sleep apnea, had a physician's order for oxygen administration via nasal cannula at two liters per minute to maintain oxygen saturation above 90%. However, the resident was documented to have received oxygen at higher rates without a corresponding physician's order. Additionally, the resident required a CPAP for sleep apnea, but there was no physician's order for its use, and the CPAP was non-functional. On one occasion, the resident's oxygen saturation dropped significantly, and despite attempts to adjust oxygen levels and use the CPAP, the saturation did not improve. The LPN involved was unaware of the resident's code status and did not initiate CPR or contact emergency services when the resident's condition deteriorated. The LPN also placed the non-functional CPAP on the resident without a physician's order. The DON later acknowledged that the CPAP order was missed and that the nurses should have adhered to the physician's orders for oxygen administration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hugo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homestead Of Hugo | 2.6 mi | ★★★★★ | 4 | 1 |
| Antlers Manor | 15.7 mi | ★★★★★ | 0 | 0 |
| Choctaw Nation Nursing Home | 16.5 mi | ★★★★★ | 0 | 0 |
| Stillhouse Rehabilitation And Healthcare Center | 22.6 mi | ★★★★★ | 0 | 0 |
| Avir At Paris | 22.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.