Below 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 Ambassador Manor Nursing Center during CMS and state inspections, most recent first.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
A resident with diabetes and other complex medical conditions had an order for daily insulin glargine that was correctly reflected on the MAR but not on the TAR. Over several days, a CMA documented the insulin order on the MAR and in progress notes and reported it to the nurse, but did not notify anyone else and believed the resident did not receive the medication. An LPN stated they only used the TAR when administering medications and did not review the MAR, resulting in the ordered insulin not being given because it was placed on the MAR instead of the TAR, leading to multiple missed doses.
A resident with a history of alcohol abuse, cannabis use, stimulant dependence, and other psychoactive substance abuse, and who was cognitively intact, was found in possession of suspected illicit drug paraphernalia after housekeeping observed a small glass pipe with residue and notified the administrator. The administrator met with the resident, revoked self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and disposed of the pipe, while nursing documentation noted continued illicit substance use and reports of providing substances to other residents. Despite a facility policy requiring prompt physician notification and documentation when changes may require physician intervention, the physician/medical director was not notified and there was no documentation of any physician notification related to the incident.
A resident with a history of substance abuse and intact cognition was found in possession of suspected drug paraphernalia after staff observed them handling a small glass pipe with residue. The administrator obtained the item from the resident and disposed of it in the trash, and nursing documentation noted ongoing illicit substance use and reports that the resident provided substances to others despite prior education and revocation of self sign-out privileges. Although facility policy and state law require reporting suspected crimes and drug paraphernalia to law enforcement and the state health department, the DON and administrator acknowledged that no reports were made to either authority.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility did not maintain complete and accurate clinical records for two residents receiving wound care and one resident receiving insulin, as required by physician orders. Documentation was missing for several wound care treatments and insulin administrations, with staff and the DON confirming that these treatments were either not documented or the records could not be found.
A resident with severe cognitive impairment, unhealed pressure ulcers, and on hospice care was observed in a room with multiple flies, with both the resident and an LPN noting the persistent fly problem. Facility policy identified mechanical controls for fly abatement, but an exterminator's report found gaps around exterior doors, and the maintenance supervisor noted that doors were often left open, allowing flies to enter.
A resident with moderate cognitive impairment and a history of anxiety and depression had a medication card containing several doses of alprazolam, along with the corresponding narcotic sheet, go missing from the medication cart. The missing medication was reported by a CMA to the DON, who was unable to determine the cause of the loss, resulting in a failure to safeguard the resident's property.
A resident with moderate cognitive impairment and a history of anxiety and depression was prescribed alprazolam as needed. When a CMA discovered that several doses of this medication and the corresponding narcotic sheet were missing, the incident was reported internally to the DON but not to law enforcement or the state health department, contrary to facility policy and state regulations.
A resident with anxiety and moderate cognitive impairment had several doses of alprazolam and the related narcotic sheet go missing from the medication cart. The CMA reported the incident to the DON, who did not obtain written staff statements or document interviews, and was unable to determine the fate of the missing medication, resulting in a failure to thoroughly investigate the allegation.
A medication cart was found unlocked and unattended outside the DON's office. A CMA later locked the cart and confirmed that facility policy requires carts to be locked when not attended.
A facility failed to properly label an enteral feeding bag for a resident with a gastrostomy. The feeding bag was observed to be dated two days prior without necessary information like the resident's name, formula type, and time of change. An RN admitted that bags were sometimes refilled instead of changed, and the DON confirmed the requirement for a 24-hour change and proper labeling.
The facility did not ensure dishes were air-dried before use. A CNA was observed preparing room trays with wet plate covers, and the dishwasher staff admitted to stacking dishes immediately after washing. The dietary manager confirmed that dishes should be air-dried before stacking.
A resident with dementia and a history of traumatic brain injury was involved in an incident where they hit an RN, who then slapped the resident. This action violated the facility's policy on resident abuse, which ensures residents' rights to be free from physical abuse.
A facility failed to provide daily nephrostomy care as ordered for a resident with urinary tract issues and anxiety. An LPN confirmed that dressings had not been changed for two days, contrary to physician orders. The DON acknowledged that care should be provided daily.
The facility failed to ensure a prescribed medication was available for administration for a resident with sepsis and hypertension. The resident was prescribed bisacodyl 10 MG suppository daily, but the medication was not documented as given or held on one day and was held on another day before being administered. The DON stated that the pharmacy delivers medication twice a day and it should not take over 24 hours to receive medication.
The facility failed to ensure accurate resident records for a resident with nephrostomy care orders. The Treatment Administration Record (TAR) indicated care was provided on two specific dates, but an LPN found that the dressings had not been changed since an earlier date, contradicting the TAR entries.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
Missed Insulin Doses Due to Transcription and MAR/TAR Workflow Errors
Penalty
Summary
The deficiency involves a failure to accurately transcribe and administer an ordered insulin medication for one resident. The resident had multiple medical diagnoses, including diabetes mellitus due to an underlying condition with diabetic amyotrophy, acute kidney failure, COPD, and hyperkalemia. Clinical discharge instructions directed administration of insulin glargine 30 units subcutaneously every 24 hours, and the facility’s physician order and MAR reflected an active order for insulin glargine 30 units subcutaneously once daily starting the day after admission. The MAR entries for several consecutive days showed a chart code indicating documentation in nurses’ notes rather than actual administration of the insulin. Progress notes documented that a CMA repeatedly noted the insulin glargine order and reported it to the nurse each morning, stating they did not administer insulin and only informed the nurse when such medications appeared on the MAR. The CMA also stated they did not inform anyone else and did not think the resident received the medication. An LPN reported that they administered medications listed on the TAR and that CMAs administered medications on the MAR, and acknowledged they did not review the MAR when giving medications, which led to the insulin being missed because it was listed on the MAR instead of the TAR. The ADON confirmed that the insulin order had been placed on the MAR rather than the TAR and that the resident had missed doses of insulin as a result of this transcription and administration process failure.
Failure to Notify Physician of Resident’s Suspected Illicit Drug Paraphernalia
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of suspected illegal drug paraphernalia found in a resident’s possession, contrary to its own Notification of Change policy. The policy, dated 06/2025, required prompt notification of the resident, physician, and representative when there is an accident involving the resident that results in injury or has the potential for requiring physician intervention, with all notifications documented in the medical record. Resident #7 was admitted with diagnoses including alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse, and had a BIMS score of 15 indicating cognitive intactness. On 02/17/26, the care plan team and administrator met with the resident and in-serviced them regarding revocation of self sign-out privileges due to non-compliance with facility rules related to smoking devices and paraphernalia, which the resident acknowledged and signed as understanding. A subsequent nurse’s note dated 02/24/26 documented that on 02/17/26 the resident had received education about revocation of self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and that the resident continued to use illicit substances and was reported to provide substances to other residents despite prior education. There was no documentation that the physician was notified of the illicit paraphernalia found on 02/17/26. The resident later stated that a methamphetamine pipe had been found in their room in February, confiscated, and thrown in the trash. The HK supervisor reported that housekeeping observed the resident place a small glass pipe with residue in a box, notified the administrator, and then accompanied the administrator to the resident’s room, where the resident handed over the suspected drug paraphernalia, which was disposed of in the trash. The medical director confirmed they were not notified of the suspected drug paraphernalia, and the DON and administrator both stated that physician notification was not documented or completed.
Failure to Report Suspected Drug-Related Criminal Activity to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to notify law enforcement and the Oklahoma State Department of Health of suspected criminal activity involving drug paraphernalia. Facility policy on Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, states that if there is a suspicion of a crime against a resident, the facility shall report the incident to the Department and law enforcement, and references Oklahoma statutes defining crime and prohibiting drug paraphernalia. Resident #7 was admitted with diagnoses including alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse, and had a BIMS score of 15, indicating cognitive intactness. A nurse’s note dated 02/17/26 documented that the care plan team and administrator met with the resident and in-serviced them regarding revocation of self sign-out privileges due to non-compliance with facility rules related to smoking devices and paraphernalia. A subsequent nurse’s note dated 02/24/26 documented that the resident had received education on 02/17/26 about revocation of self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and that the resident continued to use illicit substances and was reported to provide substances to other residents. There was no documentation that the suspected illegal activity or the paraphernalia found on 02/17/26 was reported to police or the state health department. In interviews, the resident stated that a methamphetamine pipe was found in their room and that staff confiscated and discarded it. The housekeeping supervisor reported seeing the resident place a small glass pipe with residue in a box, notifying the administrator, and accompanying the administrator when the resident surrendered the suspected paraphernalia, which was then thrown in the trash. The DON stated they followed the abuse policy but were not aware the suspected drug paraphernalia was a crime, acknowledged the incident should have been reported to the state health department, and confirmed it was not. The administrator also confirmed that neither police nor the state health department were notified of the incident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or the circumstances at the time of the deficiency are provided in the report.
Failure to Maintain Complete and Accurate Clinical Records for Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents regarding wound care and medication administration. For one resident with severe cognitive impairment and multiple ulcers, treatment sheets did not show documentation of daily dressing changes on several specified dates, despite physician orders requiring these treatments. The Director of Nursing (DON) confirmed that there was no documentation for the dressing changes on the missing dates and acknowledged that undocumented treatments are considered not done. The resident was unsure about the frequency or progression of their wound care, and the DON was unable to locate any records for the specified dates. Another resident, who was cognitively intact and had an ostomy and pressure ulcers, had physician orders for wound care to multiple sites. The treatment administration record lacked documentation for wound care on a specific date, and staff later admitted that the wound care was performed but not documented. Additionally, a third resident with diabetes and a high cognitive score had missing documentation for insulin administration on three occasions, even though the resident stated they received their insulin as ordered. The DON confirmed the absence of documentation for these medication administrations.
Failure to Control Flies in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program for the abatement of flies in one of four halls observed. During an observation of wound care, multiple flies were seen in a resident's room. The resident, who was severely impaired in daily decision making, had unhealed pressure ulcers, and was receiving hospice services, reported struggling with flies throughout the day. An LPN also commented on the severity of the fly problem in the room, and both the resident and staff were observed waving flies away during care. A review of the facility's pest control policy indicated that mechanical control measures such as window screens, screen doors, electric fans, and black light style traps were important for fly abatement. The exterminator's service report noted visible light around exterior doors, providing entry points for pests, and recommended replacing seals or door sweeps. The maintenance supervisor acknowledged the presence of flies in the facility and noted that exterior doors were often held open for extended periods, allowing insects to enter, but stated that no specific concentration of flies in any resident's room had been reported to them.
Failure to Protect Resident's Property: Missing Controlled Medication
Penalty
Summary
The facility failed to protect a resident's property from misappropriation when a medication card containing approximately six doses of alprazolam, prescribed for anxiety, and the corresponding narcotic sheet were discovered missing from the medication cart. The resident involved had diagnoses of anxiety disorder and major depressive disorder, with a BIMS score indicating moderate cognitive impairment. The missing medication was first noticed by a CMA, who was unable to locate the narcotic sheet at the nurse's desk and subsequently reported the incident to the DON. The DON confirmed being notified of the missing medications but was unable to determine what had happened to them. This incident demonstrates a failure to ensure the security of a resident's controlled medication and related documentation, as required by facility policy prohibiting misappropriation of property.
Failure to Report Suspected Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of property involving a resident's medication to local law enforcement and the Oklahoma State Department of Health (OSDH). According to facility policy, upon receiving an allegation of resident abuse, neglect, or misappropriation of property, the facility is required to begin an investigation and file reports with appropriate agencies if there is reasonable suspicion that a crime has occurred. Despite this, when a certified medication aide (CMA) discovered that a medication card containing approximately six doses of alprazolam and the corresponding narcotic sheet were missing from the medication cart, the incident was only reported internally to the Director of Nursing (DON) and not to external authorities. The resident involved had diagnoses including anxiety disorder and major depressive disorder, with a BIMS score indicating moderate cognitive impairment. The missing medication was an antianxiety drug prescribed as needed. The DON confirmed being notified of the missing medications but did not report the incident to OSDH or law enforcement, as required by facility policy and state regulations. This omission constituted a failure to follow mandated reporting procedures for suspected misappropriation of resident property.
Failure to Thoroughly Investigate Missing Medication Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of a resident's property involving a resident with anxiety disorder and major depressive disorder, who had moderate cognitive impairment as indicated by a BIMS score of 11. The incident involved the disappearance of approximately six alprazolam tablets and the corresponding narcotic sheet from the medication cart, as reported by a CMA. The CMA searched for the missing narcotic sheet at the nurse's desk but was unable to locate it and subsequently reported the missing medication to the DON. Upon notification, the DON stated that an investigation was conducted; however, no written statements were obtained from staff members, and there were no notes documenting staff interviews. Additionally, the DON was unable to determine what happened to the missing medications. The lack of thorough documentation and follow-up in the investigation process led to the deficiency cited in the report.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart on the South hall, located outside the Director of Nursing's office, was observed to be unlocked and unattended at 3:05 p.m. This cart was one of two medication carts in the area. At 3:20 p.m., a certified medication aide (CMA) approached and locked the cart. The CMA confirmed that the cart should have been locked and stated that facility policy requires medication carts to be locked when unattended. The facility had 139 residents at the time of the observation.
Improper Labeling of Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure proper labeling of an enteral tube feeding bag for a resident with a gastrostomy. The resident had a physician order for continuous feeding at a rate of 45 mL/hr. During an observation, the feeding bag was found to be dated two days prior and lacked additional required information such as the resident's name, formula type, and time of change. RN #2 acknowledged that the bag should be labeled with the date, time, and type of formula, and noted that sometimes bags were refilled instead of changed. The Director of Nursing confirmed that the tube feeding bag should be changed every 24 hours and properly labeled with the necessary details.
Failure to Air Dry Dishes
Penalty
Summary
The facility failed to ensure that dishes were properly air-dried before being used for meal service. During an observation, a CNA was seen preparing room trays with plate covers that had liquid running down the edges, indicating they were not dry. The CNA confirmed that the plate covers were not dry. Further interviews revealed that the dishwasher staff immediately stacked dishes on the rack after they came out of the dishwasher, without allowing them to air dry. The dietary manager acknowledged that dishes and plate covers should not be stacked immediately after washing but should be allowed to air dry.
Failure to Prevent Abuse of Resident
Penalty
Summary
The facility failed to prevent abuse for a resident who had diagnoses including dementia with behaviors and a history of traumatic brain injury. An incident occurred where the resident hit a registered nurse (RN), and the RN responded by slapping the resident. This incident was documented in an Incident Report Form. The facility's policy on resident abuse, neglect, and misappropriation of property states that residents have the right to be free from various forms of abuse, including physical abuse. The incident involving the RN and the resident constitutes a violation of this policy, as the RN's action of slapping the resident is considered physical abuse.
Failure to Provide Daily Nephrostomy Care
Penalty
Summary
The facility failed to ensure nephrostomy care was provided as ordered for a resident with diagnoses including acquired absence of other parts of the urinary tract and anxiety. A physician order dated 01/03/24 required the area around the left and right nephrostomy sites to be cleaned with normal saline, patted dry, and covered with a dry drainage sponge every day and as needed. On 02/05/25, an LPN was observed providing nephrostomy care and removed dressings dated 02/02/24, indicating that care had not been provided on 02/03/24 and 02/04/24. The LPN confirmed that the dressings had not been changed since 02/02/24. The Director of Nursing stated that nephrostomy care should be provided daily according to the physician order.
Failure to Ensure Timely Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure a prescribed medication was available for administration for one of three residents reviewed for medication administration. The resident had diagnoses including sepsis and hypertension and was prescribed bisacodyl 10 MG suppository daily. The physician order was dated 01/12/24. The Treatment Administration Record (TAR) for January 2024 did not document if the bisacodyl was given or held on 01/13/24 and indicated that the medication was held on 01/14/24. The medication was administered on 01/15/24. The Director of Nursing (DON) stated that the pharmacy delivers medication twice a day and that it should not take over 24 hours to receive medication from the pharmacy.
Inaccurate Resident Records for Nephrostomy Care
Penalty
Summary
The facility failed to ensure resident records were accurate for one of thirteen residents whose records were reviewed. Resident #1, who had diagnoses including acquired absence of other parts of the urinary tract and anxiety, had a physician order dated 01/03/24 for daily nephrostomy care. The Treatment Administration Record (TAR) for February 2024 documented that nephrostomy care was performed on 02/03/24 and 02/04/24. However, on 02/05/24, an LPN was observed providing nephrostomy care and found that the dressings on both nephrostomy sites were dated 02/02/24, indicating that care had not been provided on 02/03/24 and 02/04/24 as documented. The LPN confirmed that the dressings had not been changed since 02/02/24, contradicting the TAR entries.
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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 Tulsa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villages At Southern Hills | 0.5 mi | ★★★★★ | 0 | 0 |
| Colonial Manor Nursing Home | 1 mi | ★★★★★ | 2 | 0 |
| Zarrow Pointe | 1.2 mi | ★★★★★ | 2 | 0 |
| Southern Hills Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 0 |
| University Village Retirement Community | 2.6 mi | ★★★★★ | 0 | 0 |
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