Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Kingwood Skilled Nursing And Therapy during CMS and state inspections, most recent first.
The facility failed to complete and transmit required MDS assessments for three residents. One resident with moderate cognitive impairment left after dialysis and had no discharge assessment completed, while two other residents had hospital/ER transfers and returns without the required discharge return anticipated, reentry, or entry assessments. The MDS coordinators acknowledged the missing assessments and stated some were missed or overdue.
A facility failed to clearly separate the arbitration agreement from the admission agreement and did not ensure residents or representatives could sign admission paperwork without also agreeing to binding arbitration. The admission packet tied the dispute resolution provision to the admission agreement, while residents with intact cognition said they did not know what an arbitration agreement was, did not remember signing one, or were unsure if they had signed one; resident council attendees also said they were unaware of any arbitration agreement.
A resident was observed with multiple supplements at the bedside, including magnesium citrate, black elderberry, Co Q-10, Ashwagandha, and a fiber prebiotic, without a physician order permitting self-administration or documentation in the active orders. The resident had a BIMS of 15 and a self-administration assessment that deemed them safe to self-administer, but the assessment did not specify which meds were approved and the care plan lacked a self-administration focus. RN stated supplements could not be kept in the room and the DON said the resident had bought the items for discharge, though they had already been observed out in the open at the bedside.
The facility failed to complete an admission assessment for a resident after the resident returned from the hospital. Records showed the resident was discharged, later came back to the facility, and no comprehensive assessment was completed for the readmission. An MDS coordinator stated the resident should have had an admission assessment completed.
Failure to Provide Nail Care Assistance: A resident with CVA-related hemiplegia, facial weakness, dysarthria, and moderately impaired cognition was observed with long nails and brown substance under the nails on repeated observations. The care plan addressed communication needs but did not include an ADL intervention for nail care. CNA staff said nail care was done by cleaning under the nails, but the nails were not clipped because a family member wanted to do it, and the DON stated CNAs were expected to clean and trim nails for non-diabetic residents.
Expired and discontinued Lorazepam Oral Concentrate for a resident was found in the medication room refrigerator during survey. The medication had been discontinued earlier and had also passed its expiration date, despite the facility policy requiring expired meds to be removed from active supply and destroyed. A CMA removed the medication after it was identified, and the DON stated it should have been removed when discontinued or by the expiration date at the latest.
A facility failed to report and address allegations of sexual abuse involving two residents, one of whom had severe cognitive impairment and was unable to communicate. Despite staff observations of inappropriate behavior, the facility did not follow mandated reporting procedures, leading to an Immediate Jeopardy situation. Staff members expressed fear of retaliation, contributing to the lack of reporting, and the administration was not informed in a timely manner.
The facility failed to accurately code assessments for two residents. One resident with significant weight changes had assessments inaccurately documenting no weight loss or gain. Another resident with a colostomy was incorrectly assessed as not having one. These discrepancies were confirmed by MDS Coordinators.
A resident with essential hypertension did not receive their prescribed losartan potassium as ordered, with multiple doses held without physician authorization. The facility's MAR indicated the medication was withheld due to vital signs outside parameters, but no holding parameters or standing orders were documented. Interviews with staff confirmed the lack of proper documentation and notification to the physician.
The facility failed to obtain physician-ordered labs for two residents, one with major depressive disorder and liver disease, and another with seizures. The required lab tests, including CBC, CMP, and Keppra levels, were not documented or conducted as ordered, indicating a deficiency in the facility's process for managing lab orders.
CNA #10 failed to perform hand hygiene between resident interactions during an ice pass, contrary to the facility's Hand Hygiene policy. The CNA admitted to sanitizing hands every other room due to the distance between rooms, which was confirmed as non-compliant by the DON. This lapse in protocol could lead to cross-contamination among the 67 residents in the facility.
A facility failed to notify a physician when holding a resident's medication, losartan potassium, due to vital signs being outside parameters. The resident, diagnosed with essential hypertension, had their medication held multiple times without documented physician notification, contrary to facility policy. Interviews revealed no holding parameters for the medication, and standing orders were not provided to surveyors.
The facility failed to report an incident of resident-to-resident abuse to the OSDH, as required by their policy. A resident with schizophrenia was involved in an incident with another resident with Alzheimer's, resulting in a skin tear. Despite the policy mandating reporting to state authorities, the incident was only documented internally, and the Administrator confirmed no state report was filed.
The facility failed to investigate an incident where a resident with schizophrenia allegedly hit another resident with Alzheimer's, causing a skin tear. Despite the facility's policy requiring thorough investigations of abuse allegations, only an incident report was completed, and no further investigation was conducted.
A resident with major depressive disorder and liver disease required specific lab tests ordered by a third-party provider, but the facility failed to conduct these tests. Despite having a contract that outlined responsibilities, the facility did not document or collect the necessary samples, leading to a communication breakdown between the facility and the provider. Both parties acknowledged the lapse, and the facility had previously terminated contracts with the provider for other residents due to similar issues.
A resident with Alzheimer's and muscle weakness fell during a mechanical lift transfer when the lift's feet got caught under a geri chair, causing it to flip. Staff interviews revealed inconsistencies in understanding the facility's lift use policy, which requires two persons to assist. The resident was sent to the ER for evaluation.
A facility failed to coordinate care with a dialysis provider for a resident with end-stage renal disease and hypertension. Despite instructions from the dialysis center to withhold hypertension medications before dialysis, the facility continued administering them, potentially affecting fluid removal. The DON and LPN were unaware of the dialysis center's communication, and there was no evidence that the physician was informed. The medical records department could not find additional provider visits, indicating poor documentation and follow-up.
Missed and Untimely MDS Assessments
Penalty
Summary
The facility failed to ensure resident assessments were encoded and transmitted to the State within the required timeframes for three residents. For Resident #25, who had a BIMS score of 11 indicating moderate cognitive impairment, a nurse’s progress note documented that the resident refused to enter the facility after returning from dialysis, and another note stated the resident left the facility without a proper discharge or medications. The last assessment completed and transmitted was an entry tracking record, and there was no discharge assessment showing the resident had left the facility. The MDS Coordinator stated the discharge assessment should have been completed but was missed. For Resident #54, progress notes showed the resident left the facility with EMSA for the ER, was later readmitted, then hospitalized and readmitted again, and later left with EMSA to the ER once more. There were no discharge return anticipated or reentry admission assessments completed for these returns. For Resident #81, a discharge return anticipated entry assessment showed the resident was discharged and transferred to the hospital, and a later progress note showed the resident returned from the hospital, but there was no MDS entry assessment documenting the return. The MDS Coordinator stated the missing entry assessments should have been done and that the facility was behind on MDS assessments.
Arbitration Agreement Not Clearly Separated From Admission Packet
Penalty
Summary
The facility failed to clearly distinguish the arbitration agreement from the admission agreement and did not ensure residents or their representatives could sign the admission agreement without also consenting to the facility’s arbitration agreement. The admission packet’s introductory note stated that the admission agreement, including the dispute resolution provision/agreement, represented an agreement between the resident, the resident representative if applicable, and the facility. The dispute resolution section stated that by entering into the agreement both parties waived the right to have disputes decided in court and instead accepted binding arbitration as the sole means of dispute resolution, while also stating that arbitration was not a condition of admission or continued care. The administrator identified 68 residents in the facility, and the administrator and admissions coordinator stated all 68 residents or representatives had agreed to arbitration. Residents with intact cognition, including several with BIMS scores of 14 or 15, told the surveyor they did not know what an arbitration agreement was, did not remember signing one, or were unaware whether they had signed one. During resident council, attendees stated no one knew what an arbitration agreement was. The admissions coordinator stated that if a resident did not want to sign the arbitration agreement, signatures would be stopped and the packet would be reprinted so the resident would not have to sign it, and said a script was read explaining the resident did not have to sign and had 30 days to rescind in writing. The administrator stated a script was read during admission discussions and that if the resident said they understood, the administrator believed them.
Unordered and unsecured supplements observed at resident bedside
Penalty
Summary
The facility failed to ensure medications had a physician's order, were documented, and secured for one sampled resident who was observed self-administering supplements. Resident #65 was seen on 05/18/26 with a bedside table full of supplements, including magnesium citrate 250 mg, black elderberry, Co Q-10 100 mg, Ashwagandha, and a fiber prebiotic. The same supplements were again observed on the bedside table on 05/21/26 while the resident was not in the room and the roommate was present. The resident's active orders did not include the supplements or an order permitting self-administration, and the care plan did not include a self-administration focus. Resident #65 had a medication self-administration assessment dated 12/28/25 that deemed the resident safe to self-administer medications, but it did not list which medications were approved. The quarterly MDS dated 03/31/26 showed diagnoses including pain due to internal orthopedic prosthetic device, history of falling, essential hypertension, and GERD without esophagitis, and the resident had a BIMS score of 15. The resident stated they took the supplements to lose weight and maintain health and had not yet spoken with their doctor about a weight loss regimen. RN #1 stated residents could not keep supplements in their room and that all medication needed to be documented and kept in a medication cart. The DON stated the resident had purchased the medications to take with them because they were being discharged the next day, but the resident had already been observed with the medications at the bedside since 05/18/26.
Missing Admission Assessment on Readmission
Penalty
Summary
The facility failed to ensure an admission assessment was completed for Resident #4 upon readmission. Record review showed the resident was discharged from the facility and transferred to the hospital, then later returned to the facility. The MDS data entry assessment dated 04/30/26 showed the resident had returned, but there was no comprehensive assessment completed for the readmission. During an interview on 05/20/26, the MDS Coordinator stated that Resident #4 should have had an admission assessment completed for readmission to the facility.
Failure to Provide Nail Care Assistance
Penalty
Summary
The facility failed to provide nail care assistance for 1 of 4 sampled residents observed for ADLs. Resident #20 was observed in bed watching television with long nails and brown substance underneath them on 05/18/26 and again on 05/21/26. The resident was also observed trying to mumble a concern that could not be understood. The resident’s record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, facial weakness following cerebral infarction, and dysarthria following cerebral infarction. The admission assessment dated 04/15/26 showed the resident needed partial/moderate assistance with showering/bathing and substantial/maximal assistance with personal hygiene, and had a BIMS score of 8 indicating moderately impaired cognition. The care plan dated 04/28/26 addressed the resident’s communication problem but did not include an ADL intervention for nail care. RN #1 stated the resident’s nails looked like they had been growing for about a month. CNA #1 stated nail care was provided almost every day by washing the resident’s hands and cleaning under the nails, but the nails were not clipped because the resident’s family member requested to cut them. The DON stated CNAs were expected to clean and trim nails for non-diabetic residents and said the family request would have to be care planned and added.
Expired and Discontinued Lorazepam Left in Medication Refrigerator
Penalty
Summary
The facility failed to ensure discontinued and expired medications were removed from active storage for Resident #6. On 05/20/26 at 10:44 a.m., surveyors observed four syringes of Lorazepam Oral Concentrate 2 mg/mL for Resident #6 in the medication room refrigerator with an expiration date of 05/05/26. Record review showed the resident received a new order for Lorazepam Oral Concentrate 0.5 mL every four hours as needed on 02/24/26, and the medication was discontinued on 02/25/26. The facility’s Storage of Medications policy stated that all expired medications are to be removed from the active supply and destroyed in the facility regardless of the amount remaining. At 10:45 a.m., CMA #1 reviewed the expired medication and removed it from the refrigerator, stating it should have been removed when discontinued. The DON later stated the medication should have been removed when discontinued, but no later than the day it expired.
Failure to Report and Address Allegations of Abuse
Penalty
Summary
The facility failed to implement its abuse reporting policy, resulting in an Immediate Jeopardy situation. The deficiency involved a failure to report and address allegations of sexual abuse involving two residents. One resident, who had severe cognitive impairment and was unable to communicate effectively, was allegedly subjected to inappropriate behavior by another resident. This resident, who had a history of wandering and inappropriate gestures, was observed entering the room of the non-verbal resident multiple times, raising concerns among staff members. Despite these observations, the facility staff did not follow the mandated reporting procedures. Several staff members, including CNAs and RNs, were aware of the situation but did not report it to the appropriate authorities or document the incidents as required by the facility's abuse policy. The staff expressed fear of retaliation and job loss, which contributed to the lack of reporting. The facility's administration was not informed of the allegations in a timely manner, and the police were not notified until much later. The facility's failure to act promptly and follow its abuse policy resulted in a delay in addressing the potential abuse and ensuring the safety of the residents involved. The lack of documentation and communication among staff members further exacerbated the situation, leaving the residents vulnerable to harm. The deficiency highlights a significant breakdown in the facility's abuse prevention and reporting protocols, which are critical to protecting residents from harm.
Inaccurate Resident Assessments for Weight and Colostomy Status
Penalty
Summary
The facility failed to ensure accurate coding of resident assessments for two residents. Resident #23, who had diagnoses including edema and end-stage renal disease, experienced significant weight fluctuations over several months. Despite these changes, the resident's assessments on multiple occasions inaccurately documented no or unknown weight loss or gain. Specifically, the assessments on 05/02/24, 07/26/24, and 10/26/24 failed to reflect the resident's weight loss, as confirmed by the MDS Coordinators during interviews. Resident #16, who had a diagnosis that included colostomy status, was inaccurately assessed in their Annual Resident Assessment dated 11/22/24. The assessment incorrectly documented that the resident did not have an ostomy or colostomy, despite the resident having a colostomy. This discrepancy was acknowledged by the MDS Coordinators, who noted that the resident's bowel continence was not rated because it was not marked, further indicating an oversight in the assessment process.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident diagnosed with essential hypertension. The resident was prescribed losartan potassium 50 mg to be taken twice daily. However, the medication was held multiple times in October and November 2024 without obtaining an order to do so. The Medication Administration Record (MAR) documented that the medication was withheld due to vital signs being outside parameters, but there was no documentation of an order to hold the medication or any notification to the physician regarding the withheld doses. Interviews with the LPN and the Director of Nursing (DON) revealed that there were no holding parameters documented for the losartan potassium, and the facility did not have standing orders to hold the medication for low blood pressure. Despite this, the medication was repeatedly held without proper authorization or documentation. The Regional Nurse Consultant and the Administrator confirmed that the electronic record system showed medications due for each shift, and the physician should have been notified when a medication was held, but this procedure was not followed.
Failure to Obtain Physician-Ordered Labs for Residents
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for two residents, leading to a deficiency in care. Resident #37, who had diagnoses including major depressive disorder, liver disease, and unspecified viral hepatitis B, had a physician order for a CBC and CMP to be conducted every six months in October and April. However, there was no documentation that the October 2024 labs were collected. An LPN explained the process for ordering and documenting labs, but upon review, they were unable to locate the lab results in the electronic system. The Director of Nursing (DON) also confirmed that the labs were not on the monthly orders for the resident. Similarly, Resident #24, who had a diagnosis of seizures, had a physician order to draw Keppra levels every three months. The October 2024 Keppra level results were missing from the resident's record. The Regional Nurse Consultant confirmed the absence of these lab results. These lapses in obtaining and documenting necessary lab tests for residents indicate a failure in the facility's processes for managing physician orders and ensuring timely laboratory testing.
Inadequate Hand Hygiene During Ice Pass
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during an ice pass, as observed on multiple occasions. CNA #10 was seen entering several residents' rooms, handling personal cups, and distributing ice without performing hand hygiene between each resident interaction. This occurred despite the facility's Hand Hygiene policy, which emphasizes the importance of using alcohol-based hand rub after touching a resident or their immediate surroundings. During the ice pass, CNA #10 admitted to not sanitizing their hands between each resident due to the distance between rooms, opting instead to sanitize every other room. The Director of Nursing (DON) later confirmed that staff are required to sanitize their hands when moving from room to room while passing ice. The failure to adhere to these protocols was observed during the ice pass, potentially leading to cross-contamination among the 67 residents residing in the facility.
Failure to Notify Physician When Holding Medication
Penalty
Summary
The facility failed to notify the physician when holding a medication without holding parameters for a resident diagnosed with essential hypertension. The resident was prescribed losartan potassium 50 mg to be taken twice daily. However, the medication was held multiple times in October and November 2024 due to vital signs being outside parameters, as indicated by the chart code '11'. Despite this, there was no documentation that the physician was notified prior to holding the medication, which is a requirement according to the facility's policy on notifying a resident's family or physician of significant treatment changes. Interviews with LPN #6 and the Director of Nursing (DON) revealed that there were no holding parameters for the medication, and the physician was not contacted when the medication was held. The Regional Nurse Consultant and the Administrator stated that the physician would be notified when a medication was held, but standing orders to hold the medication for low blood pressure were not provided to the survey team. This lack of communication and documentation led to the deficiency identified by the surveyors.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the Oklahoma State Department of Health (OSDH) for two residents. The facility's policy mandates that all employees report any incidents of abuse, neglect, or misappropriation of property to the appropriate authorities, including the OSDH. However, in this case, an incident involving two residents was not reported as required. Resident #25, who has a diagnosis of schizophrenia, was involved in an incident with Resident #39, who has Alzheimer's disease and an unspecified mood disorder. The incident report documented that Resident #39 was found bleeding from the left cheekbone and stated that someone had hit them, with another resident identifying Resident #25 as the perpetrator. Despite the facility's policy requiring such incidents to be reported to the OSDH, there was no documentation that an incident report was sent. The Administrator confirmed that there was no state report done, only an internal incident report. This oversight indicates a failure to adhere to the facility's policy and regulatory requirements for reporting abuse, which is crucial for ensuring resident safety and compliance with state regulations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving two residents. The facility's policy on Resident Abuse, Neglect, and Misappropriation of Property requires a member of the administrative staff to conduct a thorough investigation and report all allegations to the QAPI committee and appropriate Federal and State agencies. However, in this case, the facility did not adhere to its policy, as no investigation was conducted beyond the initial incident report. The incident involved a resident with schizophrenia, who was reported to have hit another resident with Alzheimer's disease, resulting in a skin tear on the latter's left cheekbone. The incident report noted that the resident with Alzheimer's was found bleeding and claimed to have been hit, but could not identify the perpetrator. Another resident identified the aggressor, who admitted to the act. Despite these details, the facility's Administrator confirmed that no further investigation was conducted, highlighting a failure to comply with the facility's own procedures for handling abuse allegations.
Failure to Coordinate Care with Third-Party Provider
Penalty
Summary
The facility failed to coordinate care with a third-party provider for a resident diagnosed with major depressive disorder, liver disease, and unspecified viral hepatitis B. The resident required specific laboratory tests as ordered by the third-party provider, but these tests were not conducted. The facility had a contract with the third-party provider that required written authorization for medically necessary services, including lab tests. Despite receiving a communication form from the third-party provider detailing the necessary labs, the facility did not document or collect the required samples. Interviews with facility staff, including an LPN and the Administrator, revealed a lack of communication and coordination between the facility and the third-party provider. The LPN acknowledged that the lab orders were not noted, and the Administrator confirmed that the third-party provider managed the resident's labs. The third-party representative stated that the facility was responsible for completing the labs and sending the results back. Both the facility and the third-party provider admitted to a communication breakdown, resulting in the labs not being drawn. The facility had terminated contracts with the third-party provider for other residents due to ongoing issues, but the contract for this resident remained active.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in an accident. The incident involved a resident with Alzheimer's disease and muscle weakness, who was dependent on staff for all transfers. During a transfer attempt, the feet of the lift became entangled with a geri chair, causing the lift to flip over and the resident to fall to the floor. The incident note documented that the resident was found lying on their back by the sink, with no immediate injuries observed, but was sent to the ER for further evaluation. Interviews with staff revealed inconsistencies in the understanding and implementation of the facility's policy regarding lift use. While some staff members stated that the policy required two persons to assist with the lift, others mentioned the need for a third person. The incident highlighted a lack of adherence to the established policy, as the lift was not operated with the required number of staff members, leading to the accident involving the resident.
Failure to Coordinate Dialysis Care for a Resident
Penalty
Summary
The facility failed to coordinate care with a dialysis provider for a resident with end-stage renal disease and essential hypertension. The resident had physician orders to attend dialysis sessions on Tuesday, Thursday, and Saturday. However, there was a lack of communication and coordination regarding the administration of hypertension medications. A communication form from the dialysis center indicated that the resident should not receive hypertension drugs prior to dialysis, as it could prevent the removal of excess fluids due to hypotension. Despite this, the facility continued to administer medications such as losartan potassium, minoxidil, and nifedipine during the morning timeframe, which included the dialysis days. The facility's Director of Nursing (DON) and LPN were unaware of the undated communication form from the dialysis center, and there was no evidence that the physician was informed of the dialysis center's recommendation. The DON and LPN stated that the facility coordinated care by sending a dialysis communication sheet with the resident, but they did not know when or how the note from the dialysis center was added to the resident's chart. The medical records department was unable to locate any additional provider visits for the resident, indicating a lack of proper documentation and follow-up on the dialysis center's instructions.
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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 Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Place Healthcare And Rehab | 0.9 mi | — | 29 | 1 |
| Wildewood Skilled Nursing And Therapy | 2.1 mi | ★★★★★ | 0 | 0 |
| Mid-del Skilled Nursing And Therapy | 2.4 mi | ★★★★★ | 0 | 0 |
| Cross Timbers Nursing And Rehabilitation | 4.4 mi | ★★★★★ | 0 | 0 |
| The Wilshire Skilled Nursing And Therapy | 4.4 mi | ★★★★★ | 0 | 0 |
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