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 Colonial Manor Nursing Home during CMS and state inspections, most recent first.
A resident with parkinsonism and DM did not have a quarterly MDS assessment completed within the required timeframe. Facility policy required quarterly comprehensive assessments to be completed within 92 days of the last assessment, but documentation showed the resident’s next quarterly assessment, listed as due and in progress, was not completed by the due date. During interview, the MDS coordinator confirmed the assessment was overdue and should have been completed as scheduled.
Surveyors determined that the facility failed to include a leg contracture in the comprehensive, person-centered care plan for a resident with a history of stroke, osteoarthritis, and aseptic necrosis of the femur. The resident’s left leg was observed to be contracted, and the resident reported using a compression sleeve for comfort and needing pain medication. The existing care plan addressed assistance with lower body dressing and the need for a total lift for transfers but did not address the contracture. A CNA and an RN confirmed the contracture was not on the care plan they used to guide care, and both the MDS coordinator and DON acknowledged that the contracture should have been included.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to the delivery of individualized care.
The facility did not provide required quarterly financial statements to residents with trust fund accounts, as mandated by policy. Financial records for three sampled residents showed no statements were available for a six-month period, and the business office manager confirmed that statements were not provided and was unaware of the requirement.
The facility did not update care plans for two residents with significant medical histories, including stroke, Parkinson's disease, heart failure, and angina, despite changes in condition and physician orders for treatment. Diagnoses such as CVA, TIA, and angina were omitted from care plans, and one resident was found unresponsive after reporting chest pain. The MDS coordinator confirmed that these omissions were due to the diagnoses not being considered active or being overlooked.
A CMA prepared medication for a resident and gave it to another CMA, who then administered it, contrary to facility policy requiring the same person to both prepare and administer medications. Both staff and the DON confirmed this was not the approved procedure.
A resident with multiple cardiac and renal diagnoses did not receive a prescribed 24-hour transdermal nitroglycerin patch for angina pectoris. The resident later complained of chest pain and was subsequently found unresponsive. Facility leadership was unable to determine why the medication was missed, as the agency CMA responsible gave inconsistent explanations.
The facility failed to maintain a clean ice machine used by 53 residents. A slimy black substance was observed on the machine, and neither the maintenance supervisor nor the administrator knew who was responsible for its cleaning.
A resident with dementia and mood disturbances was involved in an altercation with a CMA after a delay in receiving evening medications. The resident became agitated, leading to a physical confrontation where the resident fell and sustained injuries. Witnesses provided differing accounts, and the CMA was cited for assault and battery. The facility's investigation substantiated the abuse allegation, resulting in the CMA's termination.
Failure to Complete Required Quarterly MDS Assessment on Time
Penalty
Summary
The facility failed to complete a required quarterly MDS assessment within the mandated timeframe for one resident. Facility policy titled "MDS 3.0 Completion" required that quarterly comprehensive assessments be completed no greater than 92 days from the resident’s last quarterly assessment. Record review showed that a resident with diagnoses including parkinsonism and diabetes mellitus had a quarterly assessment dated 11/18/25, and the facility’s comprehensive assessment list indicated the next quarterly assessment was due by 02/18/26 and was still listed as in progress after that date. On 03/05/26 at 7:55 a.m., the MDS coordinator confirmed that the resident’s quarterly assessment was due on 02/18/26 and acknowledged it should have been completed by that time. This deficiency involved one of three sampled residents reviewed for quarterly assessments, in a facility with 52 residents, and was based on record review and staff interview demonstrating noncompliance with the facility’s own MDS completion policy and the required quarterly assessment schedule.
Failure to Include Leg Contracture in Person-Centered Care Plan
Penalty
Summary
Surveyors found that the facility failed to develop and implement a person-centered comprehensive care plan addressing a resident’s left leg contracture. Observation on 03/04/26 at 9:53 a.m. showed the resident’s left leg was contracted, bent at the knee with the left ankle positioned under the right knee. The resident’s care plan, dated 02/23/26, documented diagnoses including osteoarthritis of an unspecified hip, cerebral infarction (stroke), and aseptic necrosis of the left femur, and noted the resident required assistance with lower body dressing and a total lift for transfers. However, the care plan did not include any problem, goals, or interventions related to the resident’s left leg contracture, despite the facility’s policy requiring a comprehensive person-centered care plan that describes services to attain or maintain the resident’s highest practicable well-being. During interview, the resident reported that the leg became contracted at another nursing facility following a stroke, that they wore a compression sleeve on the left leg for comfort, and that they required pain medication to manage pain. Staff interviews confirmed the omission: a CNA stated they used care plans to guide resident care and acknowledged the resident’s contracture was not addressed in the care plan; an RN also stated the contracture was not listed on the care plan. The MDS coordinator and the DON each stated that the resident’s left leg contracture was not included but should have been included in the care plan. These observations and interviews demonstrated that the facility did not ensure the resident’s contracture was incorporated into a person-centered comprehensive care plan as required by facility policy.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Provide Required Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide individual financial records to residents with trust fund accounts as required by policy. Record review for three sampled residents revealed that no quarterly financial statements were available for the period from January 1 to July 17, 2025. The facility's policy states that individual financial records must be available to residents through quarterly statements and upon request. During an interview, the business office manager confirmed that while residents could ask for their balance verbally, the facility did not provide quarterly statements and the manager was unaware of the requirement to do so. This deficiency was identified for all three residents reviewed for personal funds, and the administrator reported a total of 27 residents with trust fund accounts at the facility.
Failure to Revise Care Plans for Residents with Significant Diagnoses
Penalty
Summary
The facility failed to revise and update care plans for two of eight sampled residents, as required following comprehensive assessments. For one resident with a history of severe cognitive impairment, cerebral vascular accident (CVA), transient ischemic attack (TIA), and Parkinson's disease, the care plan did not address concerns related to CVA or TIA. Despite documented incidents where the resident was unable to sit up and eat, and later required emergency transfer to the hospital for a suspected stroke and was found to have a pulmonary embolism, these diagnoses were not included in the care plan. The MDS coordinator stated that these conditions were omitted because they were not considered active diagnoses at the time. For another resident with diagnoses including diabetes, heart failure, hypertension, angina pectoris, and end stage renal disease, the care plan did not address angina pectoris or heart failure, despite a physician's order for a nitroglycerin patch for angina. The CAA worksheet identified congestive heart failure and angina as concerns, but these were not reflected in the care plan. The resident later complained of chest pain and was subsequently found unresponsive in bed. The MDS coordinator acknowledged that the nitroglycerin patch and related diagnosis had been overlooked and should have been included in the care plan.
Improper Medication Administration by Multiple Staff
Penalty
Summary
A certified medication aide (CMA) was observed preparing medication for an unidentified resident and then handing the prepared medication to another CMA, who subsequently administered it to the resident. Both CMAs acknowledged during interviews that this practice was not in accordance with facility policy, which requires the person who prepares the medication to also administer it. The Director of Nursing (DON) confirmed that the facility policy does not permit one CMA to administer medication prepared by another. The incident involved the preparation and administration of medication to an unknown resident, with no explanation provided by the staff for the deviation from policy.
Failure to Administer Physician-Ordered Nitroglycerin Patch
Penalty
Summary
A review of records and interviews revealed that a resident with diagnoses including diabetes, heart failure, hypertension, angina pectoris, and end stage renal disease did not receive a physician-ordered 24-hour transdermal nitroglycerin patch for angina pectoris as documented on the medication administration record. The resident was cognitively intact, as indicated by a BIMS score of 15. On the day the medication was missed, the resident complained of chest pain to an RN, who assessed vital signs that were within normal limits. Later that same day, the resident was found unresponsive and without a pulse, and CPR was initiated. The facility's Director of Nursing (DON) and administrator were unable to determine why the nitroglycerin patch was not administered, despite attempts to contact the agency CMA responsible. The CMA provided inconsistent explanations and ultimately, the facility requested that the CMA not return. The failure to administer the medication as ordered constituted a significant medication error for the resident.
Failure to Maintain Clean Ice Machine
Penalty
Summary
The facility failed to maintain a clean ice machine, which was used by 53 residents. During an observation, a slimy black substance was found on the top and interior of the plastic cover, along each side of the water reservoir, and near the water pump of the ice machine. The maintenance supervisor acknowledged the ice machine was dirty and admitted to not knowing who was responsible for its cleaning. The administrator was also unaware of who was responsible for cleaning the ice machine and stated they would coordinate with the dietary manager and maintenance supervisor to establish a routine cleaning schedule.
Resident Abuse Incident Involving CMA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a resident with dementia, psychotic disturbance, mood disturbance, and anxiety. The resident was cognitively intact and required supervision or touch assistance for activities of daily living and ambulation. The care plan indicated the resident had the potential for verbally abusive behaviors and outlined interventions to prevent escalation. However, on the evening of the incident, the resident became agitated after a delay in receiving their evening medications, leading to a confrontation with a CMA. During the incident, the CMA attempted to administer medications to the resident, who was already angry due to the late meal service. The situation escalated when the resident began shouting and cursing at the CMA, who attempted to leave the room. The resident physically engaged the CMA, leading to a struggle where the resident fell and sustained injuries. Witnesses provided varying accounts of the altercation, with one CNA observing the resident pushing the CMA and the CMA attempting to maintain space between them. The resident later accused the CMA of assault, resulting in a city citation for assault and battery against the CMA. The facility's response included immediate notification of the DON, who initiated an investigation and suspended the CMA. The resident was sent to the hospital for evaluation of injuries, which included a laceration and bruising. The facility's policy and procedure for abuse were reviewed, and it was determined that non-compliance began at the time of the incident and ended when all staff were in-serviced on abuse and managing aggressive residents. The investigation concluded with the substantiation of the abuse allegation and the termination of the CMA.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 103 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.9 mi | ★★★★★ | 0 | 0 |
| Ambassador Manor Nursing Center | 1 mi | ★★★★★ | 4 | 0 |
| Zarrow Pointe | 2.1 mi | ★★★★★ | 2 | 0 |
| Southern Hills Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Oklahoma Memory Care Institute | 2.7 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.