On [DATE], an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) due to the facility's failure to ensure there was sufficient staff to ensure residents were safe from falls and staff could respond promptly to residents who had fallen. At 2:01 p.m., the DON (director of nurses) was notified of the existence of the IJ situation. Resident #1 had a previous heart valve replacement and received [MEDICATION NAME] (a blood thinner) once daily since [DATE]. On [DATE] at 3:25 p.m., the resident was found in her room on the floor beside her bed, lying on her right side. The resident was assessed and found to have a skin tear on her right temple. At 3:40 p.m., the resident's vital signs were taken by a certified medication aide. …
F725 citations in Oklahoma
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oklahoma cites F725 less often than its own record predicts
0.41 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oklahoma in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oklahoma surveyors wrote
F725 findings written in Oklahoma, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, and record review, it was determined the facility failed to have sufficient staff to meet the needs of the residents. The failure to have adequate staff contributed to actual harm situations related to neglect, supervision to prevent resident to resident altercations, pain management, and pharmacy services. This had the potential to affect 89 of 89 residents who resided at the facility. Findings: 1. The facility failed to provide supervision to prevent resident to resident altercations for two (#3 and #6) of two resident reviewed for supervision. From 12/13/20 through 03/09/21, resident #3 had physical altercations with other residents that resulted in bruising, scratching, and hitting. Three residents expressed fear of physical aggression from resident #3. …
Based on observation and interview, the facility failed to provide sufficient medication aide staffing to ensure residents' medication needs were being met.The regional director of operations identified 52 residents resided in the facility.Findings:On 08/06/26 at 10:44 a.m., CMA #1 was observed completing the morning medication pass. CMA #1 was observed to be one hour late filling the medication they were doing at the time.On 08/06/26 at 3:19 p.m., CMA #1 was observed still completing medication pass.On 08/05/26 at 8:55 p.m., Resident #3 stated they were not getting some of their medications and they had told the CNAs, but the CNAs had not been able to do anything because there was no CMA available.On 08/05/26 at 11:07 p.m., Resident #10 stated they received their medications late and that… …
The short window
Recent years
| Year | Share of Oklahoma citations | vs expected |
|---|---|---|
| 2023 | 0.85% | 1.05× |
| 2024 | 0.69% | 0.86× |
| 2025 | 0.32% | 0.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oklahoma surveyors cite →
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