First Shamrock Care Center

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with exit seeking behaviors had care plan interventions to address and prevent elopement for 1 (#19) of 3 sampled residents reviewed for accidents. Resident #19 eloped through a facility window. The administrator identified 16 residents at risk for elopement. On 04/28/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident with exit seeking behaviors had care plan interventions to address and prevent elopement resulting in Resident #19 eloping. On 04/28/26 at 6:43 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 04/28/26 at 6:53 p.m., the administrator was notified of the IJ situation and the IJ template was provided. [...]

Inspectors wroteBased on record review and interview, the facility failed to protect a resident's right to be free from physical abuse for 1 (#19) of 3 sampled residents reviewed for abuse. Resident #19 was physically abused by another resident. A review of an undated facility video monitoring showed Resident #20 attempted to grab a TV remote from the table where Resident #19 was. Resident #19 grabbed the remote and held onto it. Resident #20 continued attempts to take the remote from Resident #19 standing over them. Resident #19 asked Resident #20 several times not to touch it and to get away from them. Resident #19 was cussing at Resident #20 as they persisted at their approached. Resident #19 asked Resident #20 if they wanted their (curse word withheld) beat and stood up from their sitting position. Resident #20 responded, Yes, whip my [curse word withheld]. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to:a. provide adequate supervision and a secure environment to prevent elopement for a resident with known exit seeking behaviors for 1 (#19). Resident #19 eloped through a facility window, andb. implement fall interventions for 1 (#3) of 3 sampled residents reviewed for accidents. An admission assessment for Resident #19, dated 07/28/25, showed the resident wandered and their cognition was severely impaired. A wandering and elopement risk assessment for Resident #19, dated 07/28/25, had four areas marked, Yes. The assessment read in part, the resident is at risk if the answer to any question #3-#7 is yes. The areas marked yes on the assessment were placement in the facility, history of wandering, confusion and disorientation, and dementia. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure contact information for filing a complaint with the State Agency was available to the residents. The facility manager identified 37 residents resided in the facility.

Inspectors wroteBased observation and interview, the facility failed to post notice of the availability of past State survey results in areas of the facility that were prominent and accessible to the public. The facility manager identified 37 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had access to the grievance procedure. The facility manager identified 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours seven days a week. The facility manager identified 37 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure an extended menu with portion sizes was available for use during one of one meal service observed. The facility manager identified 37 residents who received meal services from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was not administered a psychotropic medication without adequate indications for its use and received gradual dose reductions for 1 (#4) of 5 sampled residents reviewed for unnecessary medications. The RNC identified 28 residents were prescribed psychotropic medications.

Inspectors wroteBased on record review and interview, the facility failed to inform a resident or their representative of the risk, benefits, and alternative treatment options prior to giving psychotropic medications for 1 (#4) of 5 sampled residents whose clinical records were reviewed for unnecessary medications. The RNC identified 28 residents were prescribed psychotropic medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (#4) of 12 sampled residents whose care plans were reviewed. The facility manager identified 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a clinical rationale from the physician was provided on a gradual dose reduction request for a antidepressant and an antipsychotic for 1 (#37) of 5 sampled residents who were reviewed for unnecessary medications. The facility manager identified 37 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure water was not utilized to puree foods for 1 of 1 breakfast meal observed. Cook #1 identified one resident on a pureed diet resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to have effective administration who utilized its resources effectively and efficiently to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. The facility administration failed to:a. provide adequate supervision and a secure environment to ensure residents at risk for elopement had not eloped for 1 (#19) of 16 sampled residents at risk for elopement. Resident #19 was at risk for wandering and elopement. The care plan for Resident #19 did not show a concern for wandering and elopement risk prior to 03/21/26. Dietary Aide #2 stated they found Resident #19 in their truck. A combined initial and final state reportable form 283, incident date of 03/21/26, showed Resident #19 was observed seated in an employee's vehicle. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical director verified the appropriateness of an antipsychotic medication for 1 (#4) of 5 sampled residents reviewed for unnecessary medications. The facility manager identified 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from abuse for 2 (#1 and #5) of 6 sampled residents reviewed for abuse. The DON reported 44 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to report allegations of abuse to the Oklahoma State Department of Health for 1 (#1) of 6 sampled residents reviewed for abuse. The DON reported 44 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough investigation after an allegation of resident-to-resident abuse for 1 (#1) of 6 sampled residents reviewed for abuse. The DON reported 44 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's care plan was updated to include an intervention related to aggressive behaviors for 1 (#1) of 6 sampled residents reviewed for care plans. The DON reported 44 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure antipsychotic medications were administered as ordered for a serious mental illness for 1 (#1) of 6 sampled residents reviewed for behaviors. The DON reported 44 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete a quarterly assessment for one (#3) of twelve sampled residents reviewed for accurate MDS assessments. The facility manager identified 40 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary was completed for one (#40) of two sampled residents for discharge summaries. The facility manager identified 40 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure opened food items were labeled with the date opened and opened food items were stored in a sealed container. The facility manager identified 38 residents received nutrition from the kitchen.

Inspectors wroteBased on observation, record reciew, and interview, the facility failed to ensure enhanced barrier precautions notifications were is place for two (#2 and #21) sampled residents reviewed for enhanced barrier precautions. The facility manager identified two residents with indwelling devices requiring enhanced barrier precautions.

Inspectors wroteBased on record review and interview, the facility failed to ensure a RN was designated to serve as DON on a full time basis. A Daily Census report, dated 01/29/24, documented 35 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a system was in place to manage and safeguard residents' personal funds for two (#3 and #4) of three sampled residents whose trust accounts were reviewed. A Resident Trust Fund report, dated 01/29/24, documented 15 residents were in the trust account.

Inspectors wroteBased on record review and interview, the facility failed to ensure a system was in place to manage and safeguard residents' personal funds to prevent misappropriation of residents' funds for two (#3 and #4) of three sampled residents who's trust accounts were reviewed. A Resident Trust Fund report, dated 01/29/24, documented 15 residents were in the trust account.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the opportunity to formulate an Advance Directive for two (#23 and #26) of 16 sampled residents reviewed for Advance Directives. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete pre-employment screening for history of abuse and neglect per their abuse policy for two (CNA #1 and RN #1) of five employee files reviewed. The current Employee List, undated, documented 39 facility employees.

Inspectors wroteBased on record review and interview, the facility failed to ensure: A. an RN worked eight consecutive hours seven days a week, and B. an RN was designated to serve as DON on a full time basis. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan had been completed within 48 hours of admission for one ( #43) of 16 sampled residents reviewed for baseline care plans. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to fully develop a comprehensive care plan for one (#26) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 40 residents with behavioral healthcare needs and 35 residents on psychoactive medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure hospitality aides did not provide feeding assistance to residents for two (#24 and #26) of two sampled residents observed being assisted during the lunch meal service. The Resident Census and Conditions of Residents report, dated 06/20/23, documented 39 residents required the assistance of one or two staff members for eating and one resident was dependent on staff for the task of eating.

Inspectors wroteBased on record review and interview, the facility failed to obtain lab as ordered per physician order for one (#21) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 06/20/23, documented 40 residents resided in the facility.