Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mitchell Care & Rehab Center during CMS and state inspections, most recent first.
The facility did not provide or document advance directive information for several residents, as required. Review of records showed that multiple residents were not given the opportunity to create or acknowledge an advance directive, and the administrator confirmed that the necessary forms were missing from their admission packets.
A resident with senile degeneration of the brain was admitted to hospice, but staff did not complete the required significant change assessment within the mandated timeframe. The quarterly assessment did not reflect the resident's hospice status, and the ADON confirmed the omission during interviews.
A resident with senile degeneration of the brain was admitted to hospice, but the care plan was not updated to reflect this change in condition as required by facility policy. The ADON confirmed the omission during an interview.
A CMA failed to follow infection control protocols by handling oral medications with bare hands during administration to a resident with chronic pain syndrome. The CMA placed a gabapentin capsule into their bare hand and, after a tramadol tablet was dropped onto the resident's shirt, picked it up with bare hands and returned it to the medication cup, contrary to facility policy. The resident then ingested both medications.
The facility failed to cover electrical outlets in key areas, posing a safety hazard. Residents with cognitive impairments were observed near these uncovered outlets, and staff interviews revealed that the issue had been known for two weeks, during which a staff member was electrocuted. Despite the incident, the administrator was unaware of the missing covers, indicating a lapse in communication and supervision.
Two residents experienced verbal abuse by a CNA, leading to a deficiency. One resident with major depressive disorder reported being called disgusting, while another with severe dementia was threatened with cigarette withholding. The facility substantiated the allegations and terminated the CNA.
A facility failed to report an allegation of abuse involving a resident with muscle weakness and chronic respiratory failure. The resident, who required assistance and used a wheelchair, reported feeling abused when an LPN refused to help them get coffee. The incident was acknowledged by the DON but was not reported to the proper authorities as required by the facility's policy.
A facility failed to investigate an abuse allegation involving a resident with muscle weakness and chronic respiratory failure. An LPN was accused of being abusive by refusing to assist the resident with a request. The incident was reported to the DON, but no formal investigation was conducted, violating the facility's Abuse Prevention policy.
The facility did not complete annual performance reviews for 18 of its 22 certified nurse aides. Only four aides had documented performance reviews, which the administrator attributed to a previous employee's oversight.
Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to ensure that residents were educated about and offered the opportunity to create an advance directive, as required. Record reviews for four sampled residents revealed that no advance directive information had been provided or documented in their electronic health records. During an interview, the administrator confirmed that there were no signed advance directive acknowledgement forms for these residents and acknowledged that the form, which is part of the admission packet, must have been omitted. The administrator also stated that the advance directive information should have been reviewed with the residents and the acknowledgement form signed at the time of admission.
Failure to Complete Significant Change Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days after a resident elected the hospice benefit. Record review showed that a resident with a diagnosis of senile degeneration of the brain was admitted to hospice care per a physician's order dated 01/16/25. However, the resident's subsequent quarterly assessment did not reflect their hospice status, and no significant change assessment was found in the electronic health record. During interviews, the ADON confirmed that the resident was admitted to hospice services and acknowledged that the required assessment had not been completed following the admission to hospice.
Failure to Update Care Plan for Hospice Admission
Penalty
Summary
The facility failed to update the care plan for a resident who was admitted to hospice care. According to the facility's policy, the comprehensive person-centered care plan or baseline care plan should be updated upon a change in condition. Record review showed that a physician's order documented the resident's admission to hospice, but there was no corresponding update in the resident's care plan to reflect this change. During an interview, the ADON confirmed that the care plan had not been updated to include the resident's hospice admission. The resident had a diagnosis of senile degeneration of the brain.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
A certified medication aide (CMA) was observed administering medications to a resident diagnosed with chronic pain syndrome, during which infection control protocols were not followed. The CMA popped a gabapentin capsule from a blister pack directly into their bare hand and, when the resident dropped a tramadol tablet onto their shirt, the CMA picked up the tablet with their bare hand and returned it to the medication cup. The resident subsequently ingested both medications. Facility policy explicitly states that pills should not be handled with bare hands, and both the CMA and the Director of Nursing (DON) acknowledged that the correct procedure was not followed during this medication administration.
Uncovered Electrical Outlets Pose Safety Hazard
Penalty
Summary
The facility failed to ensure that electrical outlets in various areas, including the East and [NAME] side hallways, nurses' stations, and living room areas, were covered with protective plates. This deficiency was observed during a survey where multiple uncovered outlets were noted. The facility's policy, dated 04/28/2022, mandates a safe and homelike environment, which includes maintaining functioning lights and reporting environmental concerns to the administrator. Despite this policy, the maintenance director did not ensure the outlets were covered, and the issue was not reported to the administrator in a timely manner. Three residents were observed in the areas with uncovered outlets. One resident with Alzheimer's disease and cognitive communication deficit was noted to be at risk for wandering and was seen ambulating around the affected areas. Another resident with dementia and disorientation was observed propelling themselves in a wheelchair without staff supervision. A third resident with diabetes and hypertension, who was moderately cognitively impaired, confirmed that the outlet covers had been missing for about a month. Staff interviews revealed that the uncovered outlets had been known for about two weeks, during which a staff member was electrocuted and sent to the emergency room. Despite this incident, the administrator was unaware of the missing covers, highlighting a lapse in communication and supervision within the facility.
Verbal Abuse by CNA Leads to Deficiency
Penalty
Summary
The facility failed to protect residents from abuse, specifically verbal abuse, by a certified nursing assistant (CNA). Resident #3, who had diagnoses including major depressive disorder and morbid obesity, reported that CNA #1 spoke to them in a mean manner and called them disgusting, which made the resident feel bad. This incident was confirmed during an interview with Resident #3, who expressed relief that CNA #1 was no longer at the facility. The resident's cognitive assessment indicated moderate impairment, yet they were able to communicate and understand others. Resident #4, diagnosed with severe vascular dementia and other impulse disorders, was also subjected to verbal abuse by CNA #1. Although Resident #4's cognitive assessment showed severe impairment, an incident report documented that CNA #1 threatened to withhold cigarettes if the resident did not stop misbehaving. Additionally, CNA #1 was overheard calling Resident #3 a disgrace. These allegations were substantiated, and CNA #1 was terminated. The facility had conducted six in-service training sessions on abuse within the last year, but these measures were insufficient to prevent the incidents.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the proper authorities for one of the four sampled residents reviewed for abuse. The facility's Abuse Prevention policy, revised in October 2024, mandates that the Administrator or designee report any allegations of abuse to the Department of Health as required. Resident #2, who had diagnoses including muscle weakness, lack of coordination, and chronic respiratory failure, required assistance for hygiene and dressing, experienced shortness of breath with exertion, was oxygen dependent, and used a wheelchair for mobility. A formal complaint was submitted to the OSDH in August 2024, alleging that an LPN had been abusive towards Resident #2 by refusing to assist them with getting a cup of coffee and instead placing a wheelchair in the resident's doorway, telling them to get it themselves. The incident was reported to the DON by the LPN, but there was no documentation that the alleged abuse was reported to the OSDH. The DON acknowledged that the incident was considered an allegation of abuse but confirmed that it was not reported to the proper authorities.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with diagnoses including muscle weakness, lack of coordination, and chronic respiratory failure. A formal complaint was submitted alleging that an LPN had been abusive towards the resident by refusing to assist them in obtaining a cup of coffee and instead placing a wheelchair in the doorway, instructing the resident to get it themselves. The LPN reported the incident to the DON but was not asked to provide a written statement or removed from their work assignment during an investigation. The DON acknowledged the resident's report of feeling abused but confirmed that no formal investigation was conducted, contrary to the facility's Abuse Prevention policy.
Failure to Conduct Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for 18 out of 22 certified nurse aides employed at the facility. The administrator confirmed that only four nurse aides had completed performance reviews, as documented in the nurse aide skills performance checklist. This deficiency was attributed to a previous employee's failure to complete the required performance reviews for all certified nurse aides, as stated by the administrator.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mcalester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Hills Living & Rehabilitation Center | 0.5 mi | ★★★★★ | 8 | 0 |
| Mcalester Nursing & Rehab | 1 mi | ★★★★★ | 0 | 0 |
| New Hope Retirement & Care Center | 1.5 mi | ★★★★★ | 8 | 0 |
| Walnut Grove Care & Rehab Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Beare Manor | 14.5 mi | ★★★★★ | 0 | 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.