Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 14 | 0 |
| 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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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.