Below 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 July 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.
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.
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.
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.
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.
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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 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 |
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