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 Fort Gibson Care & Rehab Center during CMS and state inspections, most recent first.
A resident with psychosis, hallucinations, and dementia experienced multiple falls, including a head injury, due to the facility's failure to update and implement individualized fall interventions. Despite being at risk, the care plan was not consistently updated with new interventions, and some were repeated or inappropriate. Staff interviews revealed awareness of the fall risk but acknowledged the need for better education on fall interventions.
A resident with multiple diagnoses, including muscle weakness and Parkinson's, did not receive restorative services to maintain or improve their ability to carry out activities of daily living. Despite recommendations and physician orders for restorative services following the end of physical therapy, the resident did not receive the necessary care. The DON was unaware of the recommendations and could not provide documentation of restorative services being provided.
The facility failed to maintain cleanliness and proper labeling in the kitchen. The ice scoop was found uncovered on the ice machine, and three ham sandwiches in the refrigerator were unlabeled and undated. The ovens had a thick black substance, indicating they had not been cleaned as scheduled. A cook acknowledged the need for cleaning, and the DM confirmed the oversight.
The facility failed to implement Enhanced Barrier Precautions (EBP) during resident care, as observed when a CNA assisted a resident with toileting and dressing without wearing a gown, despite EBP signage. Interviews revealed staff confusion and lack of awareness about EBP, with one CNA incorrectly describing it and another unaware of its meaning. An LPN providing wound care also failed to wear a gown, acknowledging the oversight. The ADON initiated staff re-education upon discovering the knowledge gaps.
A resident experienced a decline in ADLs following an above-knee amputation, yet the facility failed to complete a significant change assessment within the required timeframe. Initially, the resident had no functional impairments, but later assessments showed a decline in range of motion and extremity impairments. The resident was hospitalized for possible gangrene and returned with an amputation, but the necessary assessment was not conducted, as confirmed by the MDS coordinator and DON.
A facility failed to refer a resident with a new diagnosis of psychosis to the LOCEU for PASSAR consultation. The resident, with prior diagnoses of hypertension, dementia, and hallucination, was initially assessed as not having a serious mental illness. However, after being diagnosed with psychosis, the annual assessment still did not recognize this condition, and the ADON admitted to being unaware of the diagnosis, acknowledging that a referral should have been made.
A resident's care plan was not updated to include a recent surgical amputation of the left lower leg, nor the changes in abilities resulting from it. This deficiency was noted during a review of care plans, and both the MDS coordinator and DON confirmed the care plan should have been revised.
A facility failed to administer medications as ordered for a resident with hypertension, hypothyroidism, and bipolar disorder. The MAR showed blanks for levothyroxine, metoprolol, and protriptyline on multiple days, indicating a lack of documentation. A CMA and the ADON confirmed that blanks meant there was no way to verify if the medications were given.
Failure to Implement Individualized Fall Interventions
Penalty
Summary
The facility failed to update and implement individualized fall interventions in the care plan for a resident who experienced multiple falls, resulting in a head injury. The resident, who had diagnoses including psychosis, hallucinations, and dementia, was identified as being at risk for falls. Despite this, the care plan was not consistently updated with new interventions following each fall, and some interventions were repeated or deemed inappropriate for the resident's needs. The resident experienced numerous falls over several months, with incident reports documenting falls in various locations such as their room, the lobby, and near the bathroom. These incidents often resulted in injuries, including a laceration to the forehead that required sutures. The care plan interventions following these falls were inconsistent, with some incidents lacking new interventions entirely, and others including measures such as neuro checks, medication reviews, and toileting programs that were not effectively preventing further falls. Interviews with staff, including the ADON and DON, revealed that the staff were aware of the resident's fall risk and existing interventions, but acknowledged that the interventions were not always appropriate or effectively implemented. The DON noted the need for staff education regarding falls and fall interventions, highlighting a systemic issue in the facility's approach to fall management and care planning for at-risk residents.
Failure to Provide Restorative Services to Resident
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as #26, to maintain or improve their ability to carry out activities of daily living. The resident had multiple diagnoses, including muscle weakness, lack of coordination, muscle wasting and atrophy, abnormalities of gait and mobility, and Parkinson's disease. The care plan, revised in August 2023, indicated that staff should encourage the resident to participate in activities promoting exercise and physical activity for strengthening and improved mobility. It also stated that the resident should be referred to physical therapy, occupational therapy, or restorative services as needed. However, despite a physician's order in February 2024 to discontinue part B physical therapy services and allow for restorative nursing services, and a subsequent order in June 2024 for PT/OT/ST evaluation and treatment, the resident did not receive the recommended restorative services. The physical therapy discharge summary from August 2024 recommended a range of motion program and a transfer program for the resident, which were not implemented. An annual assessment in January 2025 documented that the resident was not receiving any physical therapy, occupational therapy, or restorative services, despite having limited range of motion on one side of the upper body and being dependent on assistance for transfers and most activities of daily living. Observations in January 2025 confirmed that the resident had not received restorative services since their physical therapy ended in August of the previous year. The Director of Nursing (DON) was unaware of the recommendation for restorative services and could not provide documentation that such services were ever provided to the resident.
Kitchen Cleanliness and Food Labeling Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen, affecting food safety standards. During a kitchen tour, the ice scoop was found lying uncovered on top of the ice machine, contrary to the policy that requires it to be kept in a clean and sanitary condition. Additionally, three ham sandwiches in the refrigerator were not labeled or dated, violating the policy that mandates leftovers be labeled and dated with an expiration date of no more than three days. The ovens were observed to have a thick black substance on the bottom and sides, indicating they had not been cleaned as per the cleaning schedule. Cook #1 acknowledged the ovens needed cleaning and that the ice scoop should be kept in a plastic bag, which should be changed daily. The Dietary Manager (DM) confirmed the ovens had not been cleaned according to the schedule.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure the proper implementation of Enhanced Barrier Precautions (EBP) during resident care, as observed in the case of a resident who required such precautions. The EBP policy, last reviewed on 05/15/24, mandates the use of gowns and gloves during high-contact care activities to prevent the transfer of multidrug-resistant organisms. However, during an observation, a Certified Nursing Assistant (CNA) was seen assisting a resident with toileting and dressing without wearing a gown, despite the presence of EBP signage on the resident's door. The resident had a dressing over their right foot, and the CNA was involved in activities such as placing a sock over the dressing and changing bed linens, which are considered high-contact activities requiring EBP. Further interviews with staff revealed a lack of understanding and awareness regarding EBP. One CNA incorrectly described EBP as simply using gloves at all times, while another CNA admitted to not being informed about EBP. An LPN, who was observed providing wound care without a gown, acknowledged the requirement for EBP during such procedures and mentioned the use of an app to identify residents needing EBP. The Assistant Director of Nursing (ADON) noted that re-education of staff had begun after it was discovered that some staff members had incomplete or inaccurate knowledge of EBP.
Failure to Complete Significant Change Assessment After Amputation
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who experienced a decline in activities of daily living (ADLs) following an above-knee amputation. Initially, the resident had no functional impairments in range of motion and required only supervision for walking. However, a subsequent quarterly MDS assessment revealed a decline in range of motion and impairments in both upper and lower extremities. The resident was hospitalized due to possible gangrene and returned with an above-knee amputation, as documented by a nurse. Despite these significant changes, a significant change assessment was not completed within the required 14 days, as confirmed by the MDS coordinator and the Director of Nursing (DON).
Failure to Refer Resident with New Psychosis Diagnosis for PASSAR
Penalty
Summary
The facility failed to ensure a referral was made to the Local Office of Community Engagement Unit (LOCEU) for a resident who was reviewed for Pre-Admission Screening and Resident Review (PASSAR). The resident had diagnoses including hypertension, dementia, and hallucination. Initially, the resident's Level I PASSAR assessments in 2018 and 2019 indicated no diagnosis of a serious mental illness. However, on January 11, 2024, the resident was diagnosed with psychosis not due to a substance or known physiological condition. Despite this new diagnosis, the annual assessment in August 2024 did not consider the resident as having a serious mental illness according to the state Level II PASSAR process. The Assistant Director of Nursing (ADON) later acknowledged being unaware of the psychosis diagnosis and stated that a referral should have been made to the LOCEU for consultation upon receiving the diagnosis.
Failure to Update Care Plan for Amputation
Penalty
Summary
The facility failed to update the care plan for a resident who had undergone a surgical amputation of the left lower leg. The care plan did not document the amputation or any changes to the resident's abilities resulting from the procedure. This oversight was identified during a review of the resident's care plan, which was one of thirteen reviewed for accuracy. The MDS coordinator and the Director of Nursing both acknowledged that the care plan should have been updated to reflect the resident's current condition and needs.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident diagnosed with hypertension, hypothyroidism, and bipolar disorder. The Medication Administration Records (MAR) for November and December 2024 showed blanks on multiple days for the resident's prescribed levothyroxine, a thyroid hormone medication, indicating it was not documented as administered. Additionally, in January 2025, the MAR was blank for the 2:00 p.m. dosage of metoprolol, a beta blocker for hypertension, and protriptyline, an antidepressant for bipolar disorder, on two separate days. A Certified Medication Aide (CMA) confirmed that if the MAR was blank, they could not verify if the medications were given. The Assistant Director of Nursing (ADON) also stated that blanks in the MAR meant the medication administration was not documented, leaving uncertainty about whether the medications were administered.
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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 Fort Gibson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastgate Village Care & Rehab Center | 5.5 mi | ★★★★★ | 0 | 0 |
| York Manor Nursing Home | 6.7 mi | ★★★★★ | 24 | 0 |
| Muskogee Nursing Center | 6.8 mi | ★★★★★ | 1 | 1 |
| Broadway Care & Rehab Center | 6.9 mi | ★★★★★ | 0 | 0 |
| Pleasant Valley Health Care Center | 7.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.