Complete Hospice Care of Eastern Oklahoma
A hospice in Broken Bow, Oklahoma 74728
621 South Park Drive, Broken Bow, Oklahoma 74728. (580) 584-6609.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 6 deficiencies cited in the last three years
- Not rated family caregiver rating
- 8of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
6 deficiencies cited in the last three years
The middle of the 5 hospices serving ZIP code 74728 had 4.
The last inspection on record was on Jul 16, 2026: a recertification inspection by the state.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
6 deficiencies in 1 month of the last 36. Last cited Jul 2026. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Jul 16, 2026: recertification inspection by the state6 deficiencies
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Initial assessment (42 CFR 418.54(a))
The inspectors’ words, 245 words
“Based on record review and interview, the hospice failed to ensure completion of an initial evaluation for hospice services within 48 hours from receipt of referral for three (Patients #5, 9 and 10) of 19 patients. Findings: Patient #5A review of the clinical record showed a referral for hospice services on 08/04/25 and showed start of care dated 11/13/25 (101 days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the physician and no change in orders. Patient #9A review of the clinical record showed a referral for hospice services on 03/27/26 and showed start of care dated 03/30/26 (3 days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the physician and no change in orders. Patient #10A review of the clinical record showed a referral for hospice services on 06/20/24 and showed start of care dated 06/25/24 (5 days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the physician and no change in orders. On 07/16/26 from 8:15 a.m. to 9:30 a.m., Staff B stated:The referrals are entered into the computer system as intakes upon receipt to verify patient insurance.There was no documentation in the clinical records for the delay in hospice service evaluations for patients #5, 9 and #10.”
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Content of comprehensive assessment (42 CFR 418.54(c)(7))
The inspectors’ words, 1,503 words
“Based on record review and interview, the hospice failed to ensure a bereavement care plan was initiated or was included as a part of the overall POC after the initial spiritual and bereavement assessments for 19 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and #19) of 19 patients. Findings: Patient #1A review of the clinical record showed an election of the hospice benefit on 11/13/25, and completion of the spiritual and bereavement assessments on 11/14/25. A review of a POC dated 05/02/26 to 07/10/26 and IDG updates to the POC on 05/25/26, 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #2A review of the clinical record showed an election of the hospice benefit on 09/18/25, and completion of the spiritual and bereavement assessments on 09/20/25. A review of a POC dated 05/13/26 to 07/11/26 and IDG updates to the POC on 05/23/26, 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #3A review of the clinical record showed an election of the hospice benefit on 03/03/26, and completion of the spiritual and bereavement assessments on 03/03/26. A review of a POC dated 05/31/26 to 08/28/26 and IDG updates to the POC on 05/25/26, 06/08/26 and on 06/22/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #4A review of the clinical record showed an election of the hospice benefit on 10/04/25, and completion of the spiritual and bereavement assessments on 10/16/25. A review of a POC dated 06/12/26 to 08/10/26 and IDG updates to the POC on 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #5A review of the clinical record showed an election of the hospice benefit on 04/17/25, and completion of the spiritual and bereavement assessments on 04/17/25. A review of a POC dated 06/11/26 to 08/09/26 and IDG updates to the POC on 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #6A review of the clinical record showed an election of the hospice benefit on 03/08/24, and completion of the spiritual and bereavement assessments on 03/11/24. A review of a POC dated 06/25/26 to 08/23/26 and IDG updates to the POC on 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #7A review of the clinical record showed an election of the hospice benefit on 09/03/24, and completion of the spiritual and bereavement assessments on 09/05/24. A review of a POC dated 06/25/26 to 08/23/26 and IDG updates to the POC on 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #8A review of the clinical record showed an election of the hospice benefit on 05/16/25, and completion of the spiritual and bereavement assessments on 05/16/25. A review of a POC dated 05/09/26 to 07/07/26 and IDG updates to the POC on 05/11/26, 05/25/26, 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #9A review of the clinical record showed an election of the hospice benefit on 03/30/26, and completion of the spiritual and bereavement assessments on 04/01/26. A review of a POC dated 05/29/26 to 07/27/26 and IDG updates to the POC on 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #10A review of the clinical record showed an election of the hospice benefit on 06/25/24, and completion of the spiritual and bereavement assessments on 06/26/24. A review of a POC dated 06/15/26 to 08/13/26 and IDG updates to the POC on 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #12A review of the clinical record showed an election of the hospice benefit on 07/26/24, and completion of the spiritual and bereavement assessments on 07/31/24. A review of a POC dated 05/20/26 to 07/18/26 and IDG updates to the POC on 05/25/26, 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #13A review of the clinical record showed an election of the hospice benefit on 06/06/26, and completion of the spiritual and bereavement assessments on 06/08/26. A review of a POC dated 06/06/26 to 09/03/26 and IDG updates to the POC on 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #14A review of the clinical record showed an election of the hospice benefit on 10/09/23, and completion of the spiritual and bereavement assessments on 10/12/23. A review of a POC dated 05/28/26 to 07/26/26 and IDG updates to the POC on 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #15A review of the clinical record showed an election of the hospice benefit on 05/13/26, and completion of the spiritual and bereavement assessments on 05/15/26. A review of a POC dated 05/13/26 to 07/11/26 and IDG updates to the POC on 05/25/26, 06/08/26, 06/22/26 and on 07/06/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #16A review of the clinical record showed an election of the hospice benefit on 03/13/25, and completion of the spiritual and bereavement assessments on 03/14/25. A review of a POC dated 01/07/26 to 03/07/26 and IDG updates to the POC on 01/09/26, 02/02/26 and on 02/16/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #17A review of the clinical record showed an election of the hospice benefit on 01/31/25, and completion of the initial spiritual and bereavement assessments on 02/02/25 and post death bereavement assessment on 01/15/26. A review of a POC dated 11/27/25 to 01/25/26 and IDG updates to the POC on 12/08/25, 12/22/25, and on 01/05/26 showed no bereavement care plan prior to the patient’s death on 04/14/26 and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #18A review of the clinical record showed an election of the hospice benefit on 12/08/25, and completion of the initial spiritual and bereavement assessments on 12/10/25 and post death bereavement assessment on 02/07/26. A review of a POC dated 12/08/25 to 03/07/26 and IDG updates to the POC on 12/22/25, 01/05/26 and on 01/19/26 showed no bereavement care plan prior to the patient’s death on 01/30/26 and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. Patient #19A review of the clinical record showed an election of the hospice benefit on 08/01/25, and completion of the spiritual and bereavement assessments on 08/05/25. A review of a POC dated 08/01/25 to 10/29/25 and IDG updates to the POC on 08/04/25 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC. The clinical record showed no changes in orders. On 07/15/26 1:15 p.m., Staff E stated:The bereavement assessments are completed as a part of the initial spiritual assessments and again after a patient’s death.The bereavement care plans are initiated after a patient’s death. On 07/16/26 from 8:15 a.m. to 9:30 a.m., Staff B stated:Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 15, 16 and #19 did not have bereavement care plans in place. Patients #14, 17 and #18 had bereavement care plans initiated after the patients’ deaths.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 107 words
“Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include services necessary for the palliation and management of the terminal illness (hospice diagnosis) for one (Patient #9) of 19 patients. Findings: Patient #9A review of a POC dated 05/29/26 to 07/27/26 and IDG updates to the POC on 06/08/26, 06/22/26 and on 07/06/26 failed to include interventions and goals necessary for the palliation and management of the terminal illness atherosclerotic heart disease of the coronary veins.On 07/16/26 at 8:58 a.m., Staff B stated the POC for patient #9 did not have interventions and goals for heart disease.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(1))
The inspectors’ words, 417 words
“Based on record review and interview, the hospice failed to ensure continued review and update of the hospice aide care plan for five (Patients #2, 3, 4, 7 and #10) of 19 patients. Findings: Patient #2A review of the clinical record showed a hospice aide care plan dated 09/15/25 for the episode of 05/13/26 through 07/11/26 and an order dated 05/13/26 showed hospice aide visits changed to two-person assistance. IDG meetings dated 05/23/26, 06/08/26, 06/22/26 and 07/06/26 showed no POC updates to the aide care plan. The clinical record showed hospice aide visits were conducted five times a week with 2-person assistance from 05/15/26 to 07/10/26. Patient #3A review of the clinical record showed a hospice aide care plan dated 03/02/26 for the episode of 05/31/26 to 08/28/26 showed hospice aide visits were 1-person assistance. IDG meetings dated 05/25/26, 06/08/26 and on 06/22/26 showed no POC updates to the aide care plan. The clinical record showed hospice aide visits were conducted with 1-person assistance from 06/01/26 to 06/13/26 and 2-person assistance from 06/14/26 to 06/24/26. Patient #4A review of the clinical record showed a hospice aide care plan dated 10/15/25 for the episode of 06/11/26 to 08/09/26 and an order dated 06/14/26 showed hospice aide visits changed to two-person assistance. IDG meetings dated 06/22/26 and 07/06/26 showed no POC updates to the aide care plan. The clinical record showed hospice aide visits were conducted five times a week with 2-person assistance from 06/12/26 to 07/06/26. Patient #7A review of the clinical record showed a hospice aide care plan dated 09/03/24 for the episode of 06/25/26 to 08/23/26 and an order dated 04/27/26 showed hospice aide visits changed to two-person assistance. IDG meetings dated 06/22/26 and 07/06/26 showed no POC updates to the aide care plan. The clinical record showed hospice aide visits were conducted five times a week with 2-person assistance from 06/24/26 to 07/08/26. Patient #10A review of the clinical record showed a hospice aide care plan dated 06/25/24 for the episode of 06/15/26 to 08/13/26 and an order dated 04/16/26 showed hospice aide visits changed to two-person assistance. IDG meetings dated 06/22/26 and 07/06/26 showed no POC updates to the aide care plan. The clinical record showed hospice aide visits were conducted five times a week with 2-person assistance from 06/15/26 to 07/09/26. On 07/16/23 from 8:25 a.m. to 9:16 a.m., Staff B stated the clinical record showed no hospice aide care plan updates to 2-person assistance for patients #2, 3, 4, 7 and #10.”
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Recruiting and retaining (42 CFR 418.78(c))
“645Based on record review and interview, the hospice failed to ensure volunteer recruitment efforts in calendar year 2024, 01/01/2025 to 08/31/25 and 11/01/25 to 12/31/25 for all patients and employees. Findings: A review of volunteer records showed no active, ongoing or viable volunteer recruitment efforts in calendar year 2024, 01/01/2025 to 08/31/25 and 11/01/25 to 12/31/25. On 07/15/26 at 1:00 pm, Staff D stated the hospice did not have recruitment activities for volunteers until June 2026.”
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Level of activity (42 CFR 418.78(e))
“Based on record review and interview, the hospice failed to ensure cost savings of 5% with the use of volunteers as a part of the hospice program in calendar years 2024 and 2025 for all patients and employees. Findings:A review of volunteer records showed no volunteer cost savings utilization in calendar year 2024 and a volunteer cost savings utilization rate of 0.13% in calendar year 2025. On 07/15/26 at 3:00 pm, Staff B stated the hospice had no volunteer utilization in 2024 and 2025.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 16, 2026 | Recertification inspection by the state | 6 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Mar 4, 2010.
- Ownership: for-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 11.5 nurse care minutes per routine home care day, 4.2% of skilled nursing minutes at weekends and a visit near death for 87.1% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 56% at home, 11% in assisted living, 33% in a nursing facility.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 11.5 min |
| Skilled nursing minutes at weekends | 4.2% |
| Visits near death | 87.1% of patients who died |
Who owns it?
- 8 owners or officers are people: Iren Edwards (owns 5% or more directly, 100%); Lola J Edwards (managing employee (on the payroll), 75%); Iren Edwards (corporate officer, 50%); Lola J Edwards (corporate officer, 50%); Iren Edwards (managing employee (on the payroll), 25%); Michael C West (managing employee (under contract)); Satish R Bagdure (managing employee (under contract)); Sean D Boone (managing employee (under contract)).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- In CMS’s survey of family caregivers (Oct 1, 2023 to Sep 30, 2025): 83% rated it 9 or 10 out of 10, and 88% would definitely recommend it.
- CMS’s Hospice Care Index: 8 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 99.57% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 46% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 8 of 10 |
How does it compare nearby?
- Of the 5 hospices CMS’s data show serving patients in ZIP code 74728, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 4; this one had 6.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Complete Hospice Care of Eastern Oklahoma This hospice | 6 |
| Elara Caring Xi | 4 |
| Mays Hospice Care, Inc. | 11 |
| Elara Caring Xxv | 4 |
| Sans Bois Hospice, LLC | 4 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.