Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at First Shamrock Care Center during CMS and state inspections, most recent first.
Elopement Risk Not Addressed in Care Plan: A resident with schizophrenia and dementia had documented wandering and exit-seeking behaviors, but the care plan lacked wandering/elopement interventions before the resident exited through a window and was found in a staff member’s truck. Staff interviews confirmed the resident had been trying doors, entering codes, and triggering alarms before the incident, while the DON and MDS Coordinator were unclear on how the elopement risk assessment was used and did not incorporate staff input into care planning.
A resident was physically assaulted by another resident after a dispute over a TV remote escalated into threats and repeated punches to the face. A CNA was within view, gave a brief verbal command to stop, but did not effectively de-escalate the altercation and continued passing snacks while the resident was on the floor. The injured resident had schizophrenia, dementia, and agitation, and sustained facial skin tears and difficulty standing after the assault.
A resident with wandering, dementia, and exit-seeking behaviors eloped through a room window after the window was found unsecured and easily opened, and staff interviews showed the resident had ongoing attempts to leave through doors and windows. The facility also failed to keep a fall mat in place for another high-fall-risk resident who had recent injuries from a fall; the mat was later found folded behind the bed instead of positioned at the bedside.
Failure to Post State Complaint Information: The facility did not have State complaint filing information posted in the resident halls, nurses' stations, or main living area. In a resident council interview, residents said they had not been informed of their rights or how to formally complain to the State about the care they were receiving, and the administrator confirmed the information was not posted.
Failure to Post Location of Past State Survey Results: The facility did not have posted notice in prominent, public areas showing where past State survey results could be found. During observation of the resident halls, nurses' stations, and main living area, no such information was visible. The administrator later showed the survey results binder near the entrance, and the resident council group said they did not know where to locate it. The administrator stated a sign had been posted but was removed by a resident.
A facility failed to ensure residents had access to the grievance procedure. Surveyors observed that grievance procedure information and grievance form locations were not posted in resident areas, and a resident council group stated they did not know how to file a grievance. The administrator stated the grievance procedure was not posted at the time, although grievance personnel information was posted.
RN Coverage and DON Staffing Failure: The facility failed to provide RN coverage for 8 consecutive hours a day, 7 days a week, and failed to maintain a full-time DON. Audit records showed multiple days with no RN hours, and staff confirmed there was no RN coverage on the listed dates. The facility manager also stated the facility was without a DON for several weeks.
The facility failed to have an extended menu with portion sizes available during breakfast meal service for residents receiving meals from the kitchen. Staff served scrambled eggs using inconsistent portions, and an LPN stated the proper portion size should be 4 oz. The administrator stated the facility did not have an extended menu, and the RD said they were responsible for reviewing and signing off on the regular menu, not creating menus.
Unnecessary psychotropic use without adequate indication or GDR. A resident with severe vascular dementia, depression, and anxiety received Invega Sustenna for psychotic disturbances despite charted notes showing no hallucinations or delusions and no documented schizophrenia assessment before the diagnosis appeared in the record. A pharmacist requested a GDR, but it was not completed, and the dose was later increased even though the resident’s mood was stable and staff described only occasional behaviors tied to discomfort or unmet needs.
Failure to inform a resident or representative before psychotropic medication use. A resident with severe vascular dementia with psychotic disturbance, depression, and anxiety received clozapine, buspirone, citalopram, and Invega Sustenna. The record contained a consent form for clozapine, but there was no documentation that the resident or representative was informed of the risks, benefits, or alternative treatment options before the psychotropic meds were given, and nursing notes did not show any such discussion.
Failure to develop a baseline care plan within 48 hours of admission for a resident with anxiety, severe vascular dementia with psychotropic disturbance, depression, and acute and chronic respiratory failure with hypoxia. Record review showed no baseline care plan in the EHR, and the facility manager stated the plan could not be found, meaning there was not one for the resident.
A resident with dementia and psychotic disorder was receiving haloperidol and fluoxetine, and the facility’s DRR identified gradual dose reduction requests for both meds. However, the DRR did not show a physician response to either request, and the regional nurse consultant stated the requests had not been addressed by the medical director or psych services.
Improper Use of Water in Pureed Meal Preparation: A cook pureed a resident’s breakfast items by adding unmeasured amounts of hot water to hash browns, scrambled eggs, and biscuits. The cook stated water was added until the food was pureed, and another staff member said they used a half cup of hot water and thickener if needed. The RD stated staff were not supposed to use plain water for pureed foods.
The facility failed to manage resident safety and oversight when a resident at risk for elopement exited through a window and was found in an employee's vehicle, while staff were unaware of the resident's exit-seeking behavior. The facility also failed to protect a resident from physical abuse when another resident punched the resident in the face, staff did not intervene or promptly notify the nurse, and abuse in-service training had not been completed for all staff. In addition, the facility lacked an extended menu with portion sizes during meal service and did not maintain RN coverage for 8 consecutive hours seven days a week.
Medical director oversight failed when an antipsychotic was continued for a resident with severe vascular dementia and psychotropic disturbances without clear documentation supporting schizophrenia. The chart showed Invega Sustenna was ordered for dementia-related psychotic disturbance, while a psych note listed schizophrenia and the PMHNP said they did not diagnose schizophrenia and had followed prior orders. The medical director stated they signed off on meds but did not know why the EHR listed dementia, did not know the psych note showed schizophrenia, and did not know whether a GDR or diagnostic assessment had been done.
Two residents, both with cognitive and psychiatric diagnoses, were involved in an incident where one physically struck the other, resulting in minor injury. Despite care plan interventions for agitation and aggression, the event occurred and was not reported to the DON or state health department as required. The facility's abuse prohibition policy was not effectively implemented, leading to a failure to protect residents from abuse.
A resident with severe cognitive impairment and psychiatric diagnoses physically struck another resident, and although staff intervened and assessed both individuals, the incident was not reported to the Oklahoma State Department of Health as required by facility policy. Facility leadership later acknowledged that the event should have been reported.
A resident with severe cognitive impairment and psychiatric conditions was witnessed striking another resident, resulting in minor redness. Although immediate separation and assessment occurred, the facility did not conduct the thorough investigation required by policy after the abuse allegation.
A resident with severe cognitive impairment and a history of agitation and aggression was involved in a physical altercation with another resident. Despite ongoing behavioral symptoms and a documented incident, the care plan was not updated to include new interventions addressing the aggressive behaviors.
A resident with severe mental illness and behavioral symptoms did not receive a scheduled antipsychotic injection as ordered, resulting in a significant decline in condition and increased aggressive behaviors. The omission was confirmed by facility records and staff, and additional medication was required to stabilize the resident.
A facility failed to accurately complete a quarterly MDS assessment for a resident with mood and schizoaffective disorders. Despite a recent Medication Regimen Review recommending a GDR, the quarterly assessment inaccurately documented past GDR and contraindication dates. The MDS coordinator confirmed the inaccuracy and was unaware of the facility's policy on assessment accuracy.
A facility failed to complete a discharge summary for a resident discharged against medical advice, despite policy requirements. The resident, with multiple health issues, signed an Against Medical Advice form. The facility manager acknowledged the discharge summary was not completed.
The facility did not follow its policy for labeling, dating, and storing opened food items, affecting the nutrition of 38 residents. During a kitchen tour, several opened items were found without labels or dates, including whipped topping, salad mix, shredded cheese, sliced cheeses, and dressings. The cook and CDM acknowledged the policy was not followed.
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, as required. Observations showed no precaution notifications posted, and interviews revealed that CNAs and the DON were unaware of the precautions. The facility manager admitted to a lack of staff training and signage, despite being informed about the precautions two weeks prior.
The facility failed to ensure a full-time RN was designated as the DON. Despite having 35 residents, the facility's policy requiring the DON to be a licensed RN was not met. Interviews revealed that the nurse manager, identified as the DON, was an LPN. The nurse consultant did not provide a clear answer when asked about the DON.
The facility failed to manage and safeguard residents' personal funds, resulting in unaccounted amounts for two residents. The nurse manager acknowledged discrepancies in the logs and admitted there was no proper system in place prior to her taking over.
The facility failed to manage and safeguard residents' personal funds, leading to discrepancies in the balances for two residents. The nurse manager acknowledged the lack of a proper system and multiple people filling out logs, resulting in unaccounted amounts and potential misappropriation.
Elopement Risk Not Addressed in Care Plan
Penalty
Summary
The facility failed to ensure a resident with exit-seeking behaviors had care plan interventions to address and prevent elopement. Resident #19 had diagnoses including unspecified schizophrenia and unspecified dementia with agitation, and admission and wandering/elopement risk assessments documented wandering, confusion, disorientation, dementia, and placement in the facility as risk factors. Although the resident was identified as at risk on assessments, there was no documentation of a wandering and elopement care plan prior to 03/21/26, and the MDS Coordinator stated the care plan did not have interventions for wandering. On 03/21/26, Resident #19 was found sitting in a Dietary Aide's truck behind the facility. The resident told the Dietary Aide they were looking for their underwear and became agitated because they did not want to be at the facility. A combined incident report stated the resident was an elopement risk and had exited through a window of an empty room. The window was secured after the event, and the resident was placed on one-on-one supervision with a staff member. Staff interviews showed the resident had exit-seeking behaviors before the incident. An LPN stated the resident had occasional exit-seeking behaviors since admission, and CNAs stated the resident would go to exit doors, attempt to enter codes, kick the door, and set off door alarms. The DON stated they were not sure how to determine from the elopement assessment if the resident was at risk, and the MDS Coordinator stated they were not aware of the resident's exit-seeking behaviors before the incident and did not usually use staff interviews as part of care plan development or revision.
Failure to Protect Resident from Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse when one resident physically assaulted another resident in a common area. Video monitoring showed one resident attempting to take a TV remote from the table where the other resident was seated, continuing to reach for it while standing over the resident, and ignoring repeated requests to get away. The interaction escalated after both residents exchanged verbal threats and profanity, and one resident struck the other in the face multiple times, causing the resident to fall to the floor. A CNA was within view during the altercation and was heard telling both residents to stop, but did not de-escalate the physical confrontation. The CNA was walking into the common area with a cart when the assault occurred and later stated they instructed both residents to back away from each other, then turned back to continue passing snacks. The facility manager reviewed the video and stated the CNA continued passing snacks after witnessing the altercation and after the resident was on the floor. The facility manager also stated it took about 10 to 15 minutes before the nurse on duty was notified. Resident #19 had a behavior care plan identifying the resident as at risk for verbal and physical behaviors and diagnoses including unspecified schizophrenia and unspecified dementia with agitation. A nursing note documented a skin tear to the left bridge of the nose and left inner cheek after the assault, and the initial reportable form stated the resident was punched multiple times in the face and had difficulty standing. Resident #20 had diagnoses including anxiety and Huntington’s disease, and stated they tried to take the remote because they wanted to change the TV channel and hit the other resident back after being struck.
Elopement Security and Fall Intervention Failures
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent elopement for a resident with known exit-seeking behaviors. Resident #19 had an admission assessment showing wandering and severely impaired cognition, and later assessments identified the resident as at risk for elopement based on placement in the facility, history of wandering, confusion and disorientation, and dementia. A later elopement care plan identified the resident as at risk for elopement and listed diagnoses including unspecified schizophrenia and unspecified dementia with agitation, but the care plan did not show a concern for wandering and elopement risk prior to the elopement incident. On 03/21/26, Resident #19 was found seated in a dietary aide’s truck and became agitated when told they were at the facility. The state reportable incident form stated the resident was observed in an employee’s vehicle and exited through a window of an empty room. Survey observations on 04/28/26 showed the room window had Plexiglass with a small open area along the vertical edge and could easily open when pushed gently, and the door to the room was not locked. Staff interviews indicated the resident had occasional exit-seeking behaviors since admission, continued to seek exits after the incident, and had been seen trying to leave through doors and windows. The facility also failed to implement fall interventions for Resident #3. Resident #3 had a high fall risk, required substantial to maximal assistance for transfers, and had a fall on 04/05/26 with injuries to the nose, right forehead, and right shoulder. The care plan included a fall mat at the bedside, and staff stated the resident had a lowered bed and a fall mat to help prevent future falls. However, during observation on 05/06/26, the resident was lying awake in a low bed with no fall mat visible in the room, and the mat was later found folded behind the bed. A CNA stated the mat was not where it was supposed to be when entering the room.
Failure to Post State Complaint Information
Penalty
Summary
The facility failed to ensure that contact information for filing a complaint with the State Agency was available to residents. During observation of both resident halls, both nurses' stations, and the main living area, there was no information posted regarding how to file a complaint with the State agency. In a confidential interview with the resident council group, residents stated they had not been informed of their rights or given information on how to formally complain to the State about the care they were receiving. The administrator also stated that the information on how to formally file a complaint with the State Agency was not posted at that time.
Failure to Post Location of Past State Survey Results
Penalty
Summary
The facility failed to post notice of the availability of past State survey results in areas that were prominent and accessible to the public. During observation of both resident halls, both nurses' stations, and the main living area, no posted information was seen indicating where past State survey results could be located. The administrator later showed that the survey results binder was placed to the right of the facility entrance door, and the resident council group stated they did not know where to locate the past State survey results. The administrator stated a sign had been posted to show the location of the survey results, but it had been taken down by a resident and they were not sure when it was removed.
Grievance Procedure Not Accessible to Residents
Penalty
Summary
The facility failed to ensure residents had access to the grievance procedure. On 04/28/26, surveyors observed both resident halls, both nurses' stations, and the main living area and found no information posted regarding the facility's grievance procedure or the location of grievance forms, although grievance personnel information was posted. A review of the grievance binder on 05/06/26 found no grievances. The facility's grievance policy, dated 11/28/16, states that the facility will provide a mechanism for filing a grievance or complaint without fear of retaliation or barriers of service and will provide residents, resident representatives, and others information about the mechanisms and procedure to file a grievance. During a confidential interview with the resident council group on 04/28/26, the residents stated they did not know how to file a grievance. The administrator stated on 04/28/26 that the grievance procedure was not posted at the moment.
RN Coverage and DON Staffing Failure
Penalty
Summary
The facility failed to ensure RN coverage for 8 consecutive hours seven days a week and failed to designate a registered nurse to serve as the DON on a full-time basis. The facility manager identified 37 residents in the facility. A review of the facility’s RN coverage policy, dated 01/01/26, stated that facilities are responsible for ensuring an RN provides services at least 8 consecutive hours a day, 7 days a week, and that the facility must designate an RN to serve as the DON on a full-time basis. A Punch Audit Report dated 11/01/25 through 04/26/26 showed no RN hours on multiple dates, including 10/01/25 through 10/03/25, 10/06/25 through 10/15/25, 10/18/25 through 10/19/25, 10/21/25, 10/25/25 through 10/26/25, 10/28/25, 11/01/25 through 11/02/25, 11/06/25 through 11/09/25, 11/13/25, 11/27/25, 12/04/25, 12/08/25, 12/11/25, 12/22/25, 12/25/25, and 12/31/25. The business office manager stated that between 10/01/25 and 10/14/25 the facility had no RN coverage and that there was no RN coverage on any of the listed dates. The facility manager stated the facility was without a DON from 09/18/25 through 10/14/25.
Missing Extended Menu and Portion Sizes During Meal Service
Penalty
Summary
The facility failed to ensure an extended menu with portion sizes was available during meal service for the 37 residents who received meals from the kitchen. During the survey, an extended menu was requested at entrance conference, and later the administrator brought a box of paper items to the surveyors, but no extended menu was found in it. During breakfast meal preparation, staff served scrambled eggs using a 5-ounce scoop on two plates and a 4-ounce spoon on three plates, while one staff member stated the proper portion size should be 4 ounces of scrambled eggs. The breakfast menu was stated to be biscuit and gravy, hash brown, scrambled eggs, and cold cereal. The administrator stated the facility did not have an extended menu at that time, and a staff member stated they were not told about portion sizes for serving. The registered dietitian stated they were responsible for reviewing and signing off on the regular menu and not the creation of menus.
Unnecessary Psychotropic Use Without Adequate Indication or GDR
Penalty
Summary
The facility failed to ensure a resident was not administered a psychotropic medication without adequate indications for its use and failed to provide gradual dose reductions for an antipsychotic medication. Resident #4 had diagnoses including severe vascular dementia with psychotic disturbances, depression, and an anxiety disorder due to a known physiological condition. The record showed Invega Sustenna was first ordered for the resident for vascular dementia with psychotic disturbances, and later documentation showed the resident did not have potential indicators of psychosis such as hallucinations or delusions and did not have a diagnosis of schizophrenia at that time. A pharmacist requested a gradual dose reduction for Invega Sustenna, but it was not completed, and the PMHNP stated that reducing the medication would likely worsen behavior. The resident’s record later showed new psychiatric orders increasing Invega Sustenna from 78 mg monthly to 156 mg monthly, with no documentation that the resident had been assessed for schizophrenia before that diagnosis and treatment appeared in the chart. A psychiatry note stated the resident’s mood was stable and sporadic shouting was correlated to pain, while CNA observations described occasional hollering and teeth grinding that occurred when the resident needed something or was uncomfortable. The facility manager stated a comprehensive assessment was required when a new provider took over psychotropic care and could not find documentation of a schizophrenia assessment. The medical director also stated they did not know why the EHR showed Invega Sustenna being prescribed for dementia and did not know if a GDR had been attempted or if any provider had assessed the resident for schizophrenia.
Failure to Inform Resident or Representative Before Psychotropic Medication Use
Penalty
Summary
The facility failed to inform a resident or the resident’s representative of the risks, benefits, and alternative treatment options before administering psychotropic medications. Resident #4 had diagnoses including severe vascular dementia with psychotic disturbance, depression, and an anxiety disorder due to a known physiological condition. The clinical record showed a medication consent form dated 05/05/25 for clozapine 75 mg four times a day, but there was no other documentation that the resident or representative had been informed of the risks and benefits of psychotropic medications, treatment alternatives or options, or the resident’s preferred choice of treatment before the medications were given. Physician orders showed the resident later received clozapine, buspirone, citalopram, and Invega Sustenna. Review of nursing progress notes for the past year did not show that the resident or representative had been informed about any psychotropic medications or treatment alternatives. The facility manager stated that if an antipsychotic consent form for a specific medication was not in the binder, then the facility did not have one for the resident, and also stated that if the resident or representative had been informed of the psychotropic medications or alternative treatments, it would be documented in the nursing progress notes.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours of admission for Resident #4. Record review showed the resident had diagnoses including anxiety, severe vascular dementia with psychotropic disturbance, depression, and acute and chronic respiratory failure with hypoxia, with an original admission date of 12/03/24 and a reentry date of 05/30/25. The facility’s undated policy stated that a baseline care plan would be developed within 48 hours of admission to assure the resident’s immediate care needs were met and maintained. However, review of the electronic health record did not show a baseline care plan for Resident #4, and on 05/05/26 at 1:24 p.m., the facility manager stated they could not find the baseline care plan, which meant there was not one for the resident.
Missing Physician Response to Gradual Dose Reduction Requests
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review with the medical chart and followed irregularity reporting guidelines in its policies and procedures. Record review showed that Resident #37, who was severely impaired in cognition and had diagnoses of dementia and psychotic disorder, was receiving haloperidol 10 mg at bedtime and fluoxetine 20 mg daily. A significant change assessment dated 11/06/25 documented the resident’s cognitive impairment and diagnoses, and the facility’s policy on unnecessary drugs required documentation of the rationale for continuing, discontinuing, or adjusting medications. A Medical Director Report dated 08/06/25 and an Expanded DRR report dated 02/04/26 both showed gradual dose reduction requests for haloperidol and fluoxetine, but the drug regimen review did not show a physician response to either request. During interview on 05/06/26 at 1:39 p.m., the regional nurse consultant stated that the February and August gradual dose reduction requests had not been addressed by the medical director or by psychiatric services.
Improper Use of Water in Pureed Meal Preparation
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature when plain water was used to puree foods for a resident on a pureed diet. During breakfast observation, a cook placed two hash brown patties in a blender and added an unmeasured amount of hot water before pureeing them, then later added a 5-ounce scoop of scrambled eggs to the blender with another unmeasured amount of hot water and pureed the eggs. The cook also placed one and a half biscuits in a blender and added an unmeasured amount of hot water to puree them. The cook stated they did not know how much water was added and that water was added until the food was pureed. Another staff member stated they used a half cup of hot water to puree food items and added thickener if the puree became too thin. The registered dietitian stated staff were not supposed to use plain water for pureed foods.
Failure to Ensure Resident Safety, Abuse Protection, Menu Availability, and RN Coverage
Penalty
Summary
The facility failed to administer its resources effectively and efficiently in several areas tied to resident safety and care oversight. Resident #19 was identified as at risk for wandering and elopement, but the care plan did not reflect a concern for wandering and elopement risk before the incident. A dietary aide reported finding Resident #19 in their truck, and the state reportable form stated the resident was observed seated in an employee's vehicle after exiting through a window of an empty room. The MDS Coordinator stated they were not aware the resident had exit-seeking behaviors. The facility also failed to protect Resident #19 from physical abuse by another resident. Video monitoring showed Resident #20 punching Resident #19 several times in the face, causing Resident #19 to fall to the floor and sustain facial injuries. CNA #4 did not attempt to de-escalate the altercation and continued passing snacks after witnessing the incident, and the nurse on duty was not notified for about 10 to 15 minutes. The facility manager stated CNA #4 had not received abuse in-service training after the incident and that abuse in-service training had not been completed for all staff. In addition, the facility did not have an extended menu with portion sizes available during meal service, and RN coverage was not provided for 8 consecutive hours seven days a week, with multiple dates showing no RN hours. The administrator stated the facility did not have an extended menu at that time and acknowledged there was a lack of oversight in the administration of the facility.
Medical Director Did Not Verify Appropriateness of Antipsychotic Use
Penalty
Summary
The facility failed to ensure the medical director verified the appropriateness of an antipsychotic medication for one resident. Resident #4 had diagnoses including severe vascular dementia with psychotropic disturbances, depression, and an anxiety disorder due to a known physiological condition. The resident had an active order for Invega Sustenna 156 mg/mL once a day on the 10th of the month, and the record showed it was prescribed for vascular dementia with psychotic disturbances. A quarterly assessment showed the resident did not have indicators of psychosis such as hallucinations or delusions and did not have a diagnosis of schizophrenia. A psychiatry services note later documented schizophrenia and included Invega Sustenna 156 mg/mL in the treatment plan, but there was no documentation that the resident had been assessed for schizophrenia before that diagnosis and treatment. The PMHNP stated they did not diagnose the resident with schizophrenia and had followed the previous provider's orders, and they did not know who diagnosed the resident with schizophrenia. The medical director stated they oversaw medications prescribed by psych services and signed off on all medications, but they did not know why the EHR showed Invega Sustenna was prescribed for dementia, did not know the psych notes showed schizophrenia, did not know where to find the psych notes, and did not know whether a GDR had been attempted or whether any assessments had been done to diagnose schizophrenia.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by an incident in which one resident with severe cognitive impairment, agitation, and aggressive behavior physically struck another resident. The care plan for the aggressive resident included interventions such as separating them from stressful situations and monitoring for signs of frustration, but these measures did not prevent the incident. The resident's assessment documented daily verbal behavioral symptoms and significant risk for physical illness or injury due to their condition. Following the incident, the resident who was struck was found to have slight redness behind the left ear and expressed concern about being hit again, despite stating they felt safe overall. The Director of Nursing (DON) was not aware of the incident at the time of interview and confirmed that an incident report had not been completed or reported to the state health department as required. The facility's policy prohibits all forms of abuse, but the failure to implement and follow reporting procedures contributed to the deficiency.
Failure to Report Resident-to-Resident Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health as required by policy. According to the facility's abuse prohibition policy, the Administrator or DON is responsible for initiating an immediate investigation of alleged abuse and notifying the state department within 24 hours, with a follow-up report within 5 working days. In this incident, a resident with severe cognitive impairment and multiple psychiatric diagnoses was witnessed by staff physically striking another resident near the neck, shoulder, and head area. Both residents were immediately separated and assessed, and the doctor and DON were notified. The resident who was struck did not sustain any injuries. Despite the incident meeting the criteria for reportable abuse, the event was not reported to the Oklahoma State Department of Health. Interviews with the ADON and DON confirmed that the incident should have been reported, and the DON stated they were not notified of the event. The failure to report the incident as required constitutes a deficiency in the facility's abuse reporting procedures.
Failure to Conduct Thorough Investigation After Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving a resident with severe cognitive impairment and multiple psychiatric diagnoses. According to facility policy, an immediate and documented investigation should be initiated and continue for at least 72 hours after any alleged abuse. However, after an incident where one resident was witnessed striking another near the neck, shoulder, and head area, the only documented actions were immediate separation and assessment of the residents, notification of the physician and DON, and initiation of 15-minute checks for the resident who initiated the contact. The Assistant Director of Nursing later confirmed that a thorough investigation should have been completed, indicating that the required investigative process was not followed.
Failure to Update Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to include new interventions addressing aggressive behaviors, despite evidence of ongoing behavioral issues. The resident, who had diagnoses including disorganized schizophrenia, expressive language disorder, restlessness, and agitation, was noted to have severe cognitive impairment and daily verbal behavioral symptoms that placed them at significant risk for illness or injury. Although the care plan initially addressed agitation and aggression, no new interventions were added after its initiation. An incident occurred in which the resident physically struck another resident, resulting in slight redness but no reported pain. Documentation showed that the care plan was not reviewed or revised to address this new aggressive behavior, as confirmed by facility staff.
Failure to Administer Antipsychotic Medication as Ordered
Penalty
Summary
A resident with diagnoses including disorganized schizophrenia, vascular dementia, major depressive disorder, and anxiety was prescribed an antipsychotic medication, Uzedy, to be administered as a subcutaneous injection every 28 days for management of schizophrenia. The resident's care plan identified the need for psychotropic drug use and required nursing staff to monitor and report side effects and behaviors to the physician. However, the treatment administration record showed that the scheduled injection was missed on June 1st, and this omission was confirmed by facility documentation and staff interview. Following the missed dose, the resident, who had severely impaired cognition and a history of delusions and daily verbal behavioral symptoms, experienced a significant deterioration in condition. The mental health progress note indicated that the resident continued to display physical aggression toward others despite receiving the missed dose later and being prescribed additional medication. The resident's behaviors interfered with participation in activities and social interactions, and further pharmacological intervention was required to stabilize the resident and return them to therapeutic levels.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately complete a quarterly assessment for one of the twelve sampled residents, specifically regarding the Minimum Data Set (MDS) assessments. The facility's policy on the accuracy of MDS assessments requires that the assessment accurately reflect the resident's status. The resident in question was admitted with diagnoses including mood disorder, bipolar disorder, schizoaffective disorder, and major depression. A Medication Regimen Review conducted on May 14, 2024, recommended a gradual dose reduction (GDR) for medications Venlafaxine, Trintellix, and Lamotrigine, which was denied by the doctor due to concerns that a reduction would worsen or destabilize the resident's condition. However, the quarterly assessment dated May 23, 2024, inaccurately documented the last GDR and contraindication dates as September 5, 2021, and January 4, 2023, respectively. When questioned, the MDS coordinator acknowledged the inaccuracy and was unaware of the facility's policy for accuracy of assessments.
Failure to Complete Discharge Summary for Resident Discharged Against Medical Advice
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged against medical advice. The facility's policy, revised in April 2009, requires that a discharge summary and post-discharge plan be developed when a discharge is anticipated. However, for one resident, who had multiple diagnoses including depression, protein malnutrition, Wernicke's encephalopathy, chronic systolic heart failure, mixed hyperlipidemia, cerebral infarction, and nicotine dependence, no discharge summary was found in their clinical health record. The resident signed an Against Medical Advice form, acknowledging the risks of discharging without medical advice. When asked, the facility manager admitted that they did not complete the discharge summary at the time of discharge.
Failure to Label and Store Opened Food Items
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling, dating, and storage of opened food items in the kitchen, which affected the nutrition provided to 38 residents. During an initial tour of the kitchen, several opened food items were found in the refrigerator without labels or dates, including a bag of whipped topping, a bag of salad mix, a bag of shredded cheese, sliced cheeses, and opened ranch and French dressing. Additionally, sliced cheese and ham were not stored in sealed containers. When questioned, the cook acknowledged the absence of labels and dates on these items, and the Certified Dietary Manager (CDM) confirmed that the facility's policy required all opened food items to be labeled, dated, and stored in sealed bags or containers, which was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents who required them due to the presence of indwelling devices. Resident #2, admitted with epilepsy and neuromuscular dysfunction of the bladder, had a physician order for a Foley catheter and enteral feeding tube site care. However, during an observation, no enhanced barrier precaution notification was posted outside the resident's room. Similarly, Resident #21, admitted with cerebral infarction and hyperlipidemia, had a gastrointestinal PEG tube replacement, but no notification was observed for enhanced barrier precautions. Interviews with facility staff revealed a lack of awareness and training regarding enhanced barrier precautions. CNA #2 and CNA #1 both stated they had not been trained on the subject and were unaware of the precautions. The Director of Nursing (DON) also admitted to not knowing about enhanced barrier precautions or which residents required them. The facility manager acknowledged being informed about the precautions two weeks prior but confirmed that staff had not been trained and signs had not been posted for the residents in question.
Failure to Designate a Full-Time RN as DON
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was designated to serve as the Director of Nursing (DON) on a full-time basis. A Daily Census report documented that 35 residents resided in the facility. The facility's Director of Nursing policy required the DON to be a licensed RN with experience in nursing service administration, rehabilitation, and geriatric nursing. However, an Employee Changes report did not identify any employee as the DON. During interviews, an RN and a Certified Medication Aide (CMA) both identified the nurse manager as the DON, but the nurse manager was an LPN, not an RN. When the nurse consultant was asked about the DON, they hesitated and walked away without providing an answer.
Failure to Safeguard Residents' Personal Funds
Penalty
Summary
The facility failed to ensure a system was in place to manage and safeguard residents' personal funds for two of three sampled residents whose trust accounts were reviewed. The Trust Fund Policy required proper bookkeeping techniques, including maintaining individual records for each resident with details of transactions and ongoing balances. However, discrepancies were found in the Resident Petty Cash Logs for two residents. For one resident, a balance of $455 was recorded on one date, but only $155 was carried over six days later, leaving $300 unaccounted for. For another resident, multiple discrepancies were noted, including $15 and $2.75 unaccounted for on different dates. The nurse manager, who had been managing the trust accounts since June 2023, acknowledged the discrepancies when reviewing the logs. She stated that the money was usually locked in her office closet and that multiple people filled out the logs. Despite tracking the money on logs, the nurse manager admitted that there was no system in place prior to her taking over and that she did not think any discrepancies had been identified. The lack of a proper system and the involvement of multiple staff members in managing the logs contributed to the unaccounted funds in the residents' trust accounts.
Failure to Safeguard Residents' Personal Funds
Penalty
Summary
The facility failed to ensure a system was in place to manage and safeguard residents' personal funds, leading to the misappropriation of funds for two residents. A review of the Resident Petty Cash Logs revealed discrepancies in the balances for both residents. For one resident, there was a $300 discrepancy between the balance recorded on 08/24/23 and the carry-over balance on 08/30/23. For another resident, there were discrepancies of $15 and $2.75 on different dates. The nurse manager, who has been managing the trust accounts since June 2023, acknowledged the discrepancies but stated that no system was in place before her tenure, and multiple people were responsible for filling out the logs. She also mentioned that the money was usually locked in her office closet, and staff conducted a store twice a week for residents to shop for items, but there was no clear tracking of transactions before her management. The nurse manager was unaware of any discrepancies until they were pointed out during the survey. She admitted that the facility staff kept receipts but did not have a proper system to ensure that funds were not misappropriated. The lack of a systematic approach to managing and safeguarding residents' personal funds led to unaccounted amounts and potential misappropriation. The facility's failure to employ proper bookkeeping techniques and maintain accurate individual records for each resident's transactions contributed to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 14 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kingfisher
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cimarron Nursing Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Hennessey Nursing & Rehab | 18.2 mi | ★★★★★ | 7 | 0 |
| El Reno Post-acute Rehabilitation Center | 21.6 mi | ★★★★★ | 0 | 0 |
| River Oaks Skilled Nursing And Therapy | 21.9 mi | ★★★★★ | 0 | 0 |
| Heritage At Brandon Place Health & Rehabilitation | 23.7 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.