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 Leisure Village Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain comfortable water temperatures in all shower rooms, resulting in water that quickly became uncomfortably cold during use. Temperature checks by surveyors showed significant drops from initially warm or hot water to much cooler levels within minutes in multiple shower rooms. A resident reported that shower water became "ice cold" after a brief period and that they avoided showers, while others described the water as "freezing" and "frigid." CNAs reported that water turned very cold within a few minutes, forcing them to rush bathing and leading some residents to refuse showers. Staff stated they had reported the issue to maintenance several times, but the maintenance supervisor admitted there were no routine water temperature checks or logs, and the administrator acknowledged the water was too cold for them to take a shower.
Surveyors found that dietary staff lacked proper training and competency to operate the low-temperature dish machine. Two dietary aides relied on the presence of suds and visual checks of a temperature gauge instead of using required test strips or documented temperature checks, and one aide stopped the dish machine mid-cycle and walked away. One aide reported receiving informal training from another staff member and had not been taught how to check temperatures or use test strips, despite frequent use of the machine. The DM could not produce quarterly training records, 90-day nutrition services training, or annual competency documentation for dietary staff and acknowledged that, although procedures were reviewed in orientation, staff did not understand or follow the required dish machine testing process.
The facility failed to ensure proper sanitation and monitoring of dishware and cooking utensils for residents receiving meals from the kitchen. Surveyors observed a low-temp dishwasher stopped mid-cycle with suds in the reservoir and a temperature around 140°F, while the warewashing log lacked required daily documentation for multiple days. Staff reported hot water problems, use of three plastic tubs with heated water from the stove, and reliance on paper products, but the dietary manager and other dietary staff did not check or document water or sanitizer temperatures as required. One dietary aide relied only on the dishwasher gauge and visible suds and did not use test strips, while another had not been trained to test the machine. The administrator and dietary manager acknowledged uncertainty and lack of documentation regarding required daily dishmachine testing.
The facility did not consistently notify resident representatives of significant changes in condition for two residents, including new diagnoses, medication changes, and a fall. Documentation and interviews revealed that while physicians were informed, representatives were not always notified, and staff had inconsistent understanding of notification requirements.
A resident with hypertension and intact cognitive status frequently left the facility independently in a motorized wheelchair, sometimes signing out and sometimes requiring staff assistance. The care plan did not address the resident's ability to sign out, their preference for outdoor activities, or the need for staff involvement in the sign-out process, despite facility policy and observed behaviors. Staff confirmed these elements were not included in the care plan.
A resident in a long-term care facility was verbally abused by a staff member, as reported by the resident's roommate who overheard the staff member cursing. The facility's investigation substantiated the verbal abuse incident.
The facility experienced a 12% medication error rate due to errors in administering medications to two residents. One resident did not receive their prescribed medications for GERD and constipation, while another received the wrong ophthalmic solution at an incorrect time. The errors were attributed to CMAs forgetting to review the MAR and administering medication at the resident's request.
The facility failed to ensure medications were labeled and dated when opened, as observed in four medication and treatment carts. Staff acknowledged the requirement to date medications upon opening, yet several items, including insulin pens and inhalers, were found without dates. Additionally, some medications lacked proper labeling with the resident's name and dosage information.
A resident with multiple diagnoses, including multiple sclerosis and chronic pain, had a physician's order for a catheter privacy bag to be in place every shift. However, observations revealed the catheter bag was visible from the hallway without a privacy bag. The resident preferred the bag to be covered, but staff only did so upon request. A CNA admitted the oversight, and the DON expected privacy bags for all residents with indwelling catheters.
A resident with contractures did not receive recommended restorative services for contracture management, as indicated by a PT evaluation. Despite a physician's order for hand roll use and observations of positioning aids, there was no documentation of restorative services being provided. The DON and corporate RN could not locate records of the program's initiation or follow-up, and the former DON noted the resident was not agreeable to therapy.
A facility failed to properly position a urinary catheter bag for a resident, as it was observed on the floor on two occasions. A CNA confirmed the improper placement, and the DON acknowledged the absence of a policy regarding catheter bag positioning.
The facility failed to label, date, and store food items according to policy, affecting 77 residents. Surveyors found unlabeled and undated frozen biscuits and cookies, as well as an unsecured bag of lettuce without a label or date. The DM confirmed that all leftover food should be securely closed and labeled with a date.
A facility failed to implement enhanced barrier precautions during peg tube care for a resident with dysphasia. Despite signage and supplies being present, an LPN administered medication without wearing a gown, and stated the resident was not on infection control precautions. The infection preventionist and DON confirmed that such precautions should be used, but a policy had not been implemented.
A facility failed to ensure the required two-person assist during a mechanical lift transfer for a resident with a femur fracture and dementia, resulting in the resident falling. Despite training, only one CNA was present during the transfer, contrary to the care plan and safety protocols.
A resident with cognitive decline and dementia was left upset and partially clothed after a CNA improperly performed perineal care by picking off dry material with their hands instead of using wipes and cleanser. The CNA did not inform other staff of the resident's condition, leaving the resident without proper assistance and with the door open. The DON confirmed the CNA did not follow facility policy.
A CNA failed to provide perineal care according to accepted standards for a resident. The CNA found the resident with vaginal discharge and, instead of using a cleanser and wipes, attempted to pick the dry discharge off with their hands, causing discomfort. The DON confirmed this was substandard care.
The facility failed to provide showers for two residents who required assistance with activities of daily living. One resident, with COPD and Parkinson's, reported not having a shower in over a week due to staffing issues. Another resident stated they only received showers when they had a doctor's appointment. CNAs confirmed time constraints and inconsistent documentation of showers. The DON acknowledged the issue and mentioned plans to hire bath aides.
The facility failed to answer call lights promptly, as documented in resident council minutes and grievance logs. Residents reported waiting up to an hour, with one experiencing a colostomy bag burst due to delays. Staff acknowledged call lights should be answered within 5-10 minutes, but no written policy existed to enforce this standard.
A CMA was observed using bare fingers to break a potassium pill before giving it to a resident, acknowledging that gloves and a pill cutter should have been used, indicating a breach in infection control practices.
Failure to Maintain Comfortable Shower Water Temperatures
Penalty
Summary
The facility failed to maintain comfortable water temperatures in all five shower rooms, affecting residents' right to a safe, clean, comfortable, and homelike environment. Surveyors measured water temperatures in multiple shower rooms over two days and found that while initial temperatures were within or near a comfortable range, they dropped significantly within minutes. In the large South shower, water started at 100.4°F and fell to 77.4°F within 11 minutes. In the small East shower, water began at 107.4°F and dropped to 85.2°F within eight minutes. The large East shower showed a relatively stable temperature (97.6°F to 98.4°F within one minute), but the North shower dropped from 81.3°F to 70.5°F within two minutes, and the small South shower decreased from 104.6°F to 85.8°F within five minutes. Facility policy on ADL bathing required ensuring the bathing area was at a comfortable temperature, and a maintenance document dated 11/17/25 noted that hot water was not working on the north hall. Residents and staff reported ongoing problems with shower water becoming uncomfortably cold. One resident stated the shower water was warm for about two minutes and then became "ice cold," leading them to avoid taking many showers. Another resident reported that within five minutes the water became "freezing" and described it as "frigid," while another said the water on the north hall became freezing within a minute. CNAs reported that when they started showers, the water turned very cold within about three minutes, forcing them to hurry to rinse soap off residents and resulting in residents feeling their showers were cut short or refusing showers because they knew the water would get cold quickly. Staff also stated they had reported the cold water issue in the shower rooms to the maintenance supervisor several times. The maintenance supervisor acknowledged they did not perform routine water temperature checks and had no temperature logs, and the administrator stated that after feeling the water from the north hall shower, they personally would not take a shower in that water because it was too cold.
Inadequate Training and Competency of Dietary Staff in Dish Machine Operation
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure dietary staff were properly qualified and competent to operate the dishwashing equipment and carry out food and nutrition services. The DON reported that 81 residents received nutrition from the kitchen, and the DM reported there were 11 dietary staff members. During observation, two dietary aides were seen operating a low-temperature dish machine when one aide stopped the machine mid-wash cycle and walked away. One aide stated they determined the water was not hot enough by observing suds in the side tank and would wait and then try running the dishwasher again, rather than using the temperature gauge or test strips. The same aide reported working at the facility for about a month and stated they had been trained by another staff member but had not been instructed on checking the dish machine temperature or using test strips, despite using the machine several times a day. The other aide stated they checked the temperature gauge to ensure it was between two green lines and knew there were strips to check the machine but did not know where they were kept and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. The DM later stated they were unable to locate quarterly training documents, 90-day nutrition services training, or annual competencies for dietary staff, and although they reported reviewing dish machine temperature and sanitation strip procedures during orientation, they acknowledged staff were not following or understanding the required testing process or frequency.
Failure to Ensure Proper Dishwashing Sanitation and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper sanitation of dishware and cooking utensils in accordance with professional standards and its own warewashing policy. Surveyors observed a low-temperature dishwasher being stopped mid-cycle by a dietary aide, with visible suds in the reservoir and a gauge reading around 140°F. The facility’s warewashing policy required dishware to be washed in a three-sink unit with sanitizer or disposable dishware to be used if the dish machine was not working or not meeting regulatory requirements, and required daily checks and documentation of sanitizer test strip results. The warewashing log for the dishmachine showed entries marked through one date with a note that hot water was being installed, and no documentation of testing or results for several subsequent days, despite the Director of Nursing identifying that 81 residents received nutrition from the kitchen. Staff interviews revealed that hot water had been an issue and a new hot water tank was being installed, during which time staff reported washing dishes in tubs, heating water on the stove for pots, pans, and utensils, and using paper plates and containers for resident meals. The dietary manager and cook stated they were using three plastic tubs and sanitizer but did not know they needed to check or document water or sanitizer temperatures in the tubs. One dietary aide stated they only checked that the dishwasher gauge was between two green lines, knew test strips existed but did not know their location, and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. Another dietary aide reported not being shown how to check water temperature or use test strips and had been trained only by another staff member. The administrator acknowledged being unsure whether staff were completing dish machine testing due to lack of documentation, and the dietary manager later confirmed that temperature and sanitizer checks and documentation had not been completed for several days, attributing this to miscommunication among staff.
Failure to Notify Resident Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure that resident representatives were notified of significant changes in condition for two of four sampled residents. For one resident with diagnoses including congestive heart failure and obstructive sleep apnea, documentation showed that the physician was notified and new medications were ordered following complaints of nausea and an elevated A1C level, which led to a new diagnosis of type II diabetes mellitus. However, there was no documentation that the resident's representative was informed of the new medications, abnormal laboratory results, or the new diagnosis. The resident's representative confirmed limited contact from the facility since admission. For another resident with diabetes mellitus and muscle weakness, a nurse note indicated that after a fall from the bed, the physician, DON, and family member were reportedly notified. However, the family member stated they were not informed of the fall. Interviews with nursing staff revealed inconsistent understanding of when to notify resident representatives, particularly for cognitively intact residents, with some staff believing notification was not always necessary unless requested by the representative.
Failure to Develop Comprehensive Care Plan for Resident's Independent Outings
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident who was cognitively intact and had a diagnosis of hypertension. The resident was able to leave the facility independently in a motorized wheelchair and enjoyed spending time outside. Facility policy required residents to sign out when leaving the premises, but documentation showed that the resident sometimes signed themselves out, while at other times staff signed out on their behalf. There were instances where the resident left the facility without signing out or alerting staff, as noted in nurse documentation and staff interviews. Despite the resident's established pattern of independent outings and the need for adherence to the sign-out protocol, the care plan did not address the resident's ability to sign out, their enjoyment of outdoor activities, or the need for staff involvement in the sign-out process. Interviews with staff, including the DON and care plan coordinator, confirmed that these aspects were not included in the resident's care plan, and the care plan coordinator acknowledged the omission.
Verbal Abuse Incident in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically in the case of a resident who was verbally abused by a staff member. The incident was reported by the resident's roommate, who overheard the staff member cursing while speaking to the resident. This verbal abuse was substantiated by the facility's investigation, which confirmed the occurrence of the incident.
Medication Administration Errors Lead to 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12% error rate during medication administration. This was observed over 25 opportunities, with three medication errors identified. One incident involved a resident with diagnoses of GERD and constipation, who did not receive their prescribed medications, docusate sodium and famotidine, during a medication pass. The Certified Medication Aide (CMA) responsible for administering the medications admitted to forgetting to review the Medication Administration Record (MAR) to obtain the medications from the house stock supply. Another incident involved a resident with glaucoma, who was prescribed bimataprost ophthalmic solution to be administered at bedtime. Instead, the CMA administered latanoprost ophthalmic solution earlier than the prescribed time, at the resident's request. The Director of Nursing (DON) confirmed that the medication was administered at the wrong time, despite the medications being considered interchangeable. The Assistant Director of Nursing (ADON) stated that they monitored medication administration three times a week but had not observed these specific errors.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated when opened, as observed in four medication and treatment carts. During the survey, it was noted that medications on the north hall medication cart, east hall treatment cart, south hall medication cart, and south hall treatment cart were opened but not dated. Staff members, including CMAs and LPNs, acknowledged that medications should be dated upon opening, yet several items were found without dates. These included a bottle of milk of magnesia, glucometer check strips, insulin pens, inhalers, and nasal sprays. Additionally, some medications lacked proper labeling with the resident's name and dosage information, as required. The DON confirmed that medications should be dated when opened and should have a pharmacy label with the resident's name and dosage. The failure to adhere to these protocols was observed across multiple carts, indicating a systemic issue in the facility's medication management practices.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to maintain a resident's dignity by not using a privacy bag over an indwelling catheter bag for one of the residents reviewed for dignity. The resident, who was admitted with multiple diagnoses including multiple sclerosis, anxiety, depression, urogenital implants, and chronic pain, had a physician's order to verify the dignity bag was in place every shift. Despite this order, observations on multiple occasions revealed that the resident's catheter bag was visible from the hallway without a privacy bag in place. The resident expressed a preference for the catheter bag to be covered, indicating that staff only covered it upon request. A CNA acknowledged that the resident should have a catheter privacy bag in place at all times but admitted it was missed because the resident had not been getting out of bed as much. The Director of Nursing also stated that they would expect any resident with an indwelling catheter to have a privacy bag in place, highlighting a lapse in adherence to the facility's dignity policy.
Failure to Provide Recommended Restorative Services for Contracture Management
Penalty
Summary
The facility failed to provide range of motion (ROM) services to a resident with contractures, as recommended by a physical therapist (PT). The resident had diagnoses including contracture to the right elbow, wrist, and hand. A PT evaluation dated 03/30/24 indicated that the resident was not a candidate for skilled PT but would benefit from a restorative program for geri chair positioning and contracture management. Despite this recommendation, there was no documentation in the clinical record that the resident received restorative services. A physician's order dated 07/19/24 instructed the use of a hand roll for the left hand daily, and the resident was observed with hand rolls and positioning pillows. However, the Director of Nursing (DON) and corporate RN could not find documentation that the restorative program was initiated or followed up on, and the former DON indicated the resident was not agreeable to restorative therapy at that time.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure proper positioning of a urinary drainage bag for a resident with a urinary catheter. On two separate occasions, the resident was observed in bed with the urinary catheter bag placed on the floor. A Certified Nursing Assistant (CNA) acknowledged that the urinary catheter bag should not be on the floor. Additionally, the Director of Nursing (DON) confirmed that the facility did not have a policy regarding the positioning of urinary catheter bags, but agreed that the bag should not have been on the floor.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were labeled, dated, and stored according to its policy, which affected 77 residents receiving services from the kitchen. During an observation, surveyors found an unlabeled and undated zip lock freezer bag containing frozen biscuits and another with frozen cookies in the freezer. Additionally, an opened and unsecured bag of lettuce was observed without a label or date. The facility's policy, revised on 08/21/24, requires all leftovers to be labeled and dated with an expiration date. The Dietary Manager (DM) confirmed that all leftover food should be securely closed and labeled with a date.
Failure to Implement Enhanced Barrier Precautions for Peg Tube Care
Penalty
Summary
The facility failed to ensure the use of enhanced barrier precautions during peg tube care for a resident diagnosed with dysphasia. On August 20, 2024, enhanced barrier precautions signage and supplies were observed on the resident's door. However, an LPN was observed administering medication via the peg tube without wearing a gown. The LPN stated that the resident was not on infection control precautions. On August 23, 2024, the infection preventionist confirmed that enhanced barrier precautions should be used for peg tube care, among other procedures. The Director of Nursing also acknowledged that enhanced barrier precautions should be used for peg tube care and admitted that an enhanced barrier precaution policy had not yet been implemented.
Failure to Ensure Adequate Staffing During Mechanical Lift Use
Penalty
Summary
The facility failed to ensure the required number of staff were present when operating a mechanical lift for a resident with a history of a left femur fracture and dementia. The resident's care plan specified the need for a two-person assist during transfers using a mechanical lift. However, an incident occurred where the resident was found on the floor next to the Hoyer Lift with the sling still under her, indicating that the lift was operated by only one staff member at the time of the incident. Interviews with multiple CNAs confirmed that they had been trained and inserviced on the proper use of the Hoyer Lift, which requires two staff members to operate. Despite this training, the incident report and the resident's account revealed that only one CNA was present during the transfer when the resident fell. This deficiency highlights a failure in adhering to the care plan and established protocols for safe mechanical lift operation, leading to the resident's fall.
Failure to Maintain Resident Dignity During Perineal Care
Penalty
Summary
The facility failed to maintain the dignity of a resident during and after perineal care. A CNA attempted to clean a resident's vaginal area by picking off dry material with their hands instead of using wipes and cleanser, which upset the resident and caused them to cry. The CNA did not complete the care properly, as they left the resident partially clothed and did not close the door upon leaving the room. Furthermore, the CNA did not inform other staff members of the resident's condition, leaving the resident without proper assistance. The incident involved a resident with age-related cognitive decline and dementia, highlighting their vulnerability. Other CNAs observed the resident's condition after the initial CNA left, noting that the resident was only partially dressed and the door to their room was open. The Director of Nursing confirmed that the CNA did not follow the facility's policy, which requires informing other staff members of a resident's condition and using appropriate cleaning methods during perineal care.
Inadequate Perineal Care by CNA
Penalty
Summary
The facility failed to ensure that a CNA provided perineal care in accordance with accepted standards for one resident. During an inspection, CNA #1 was asked to supervise the memory care unit and found a resident lying on their bed fully clothed. Upon detecting a foul smell, CNA #1 removed the resident's jeans and instructed them to remove their briefs, finding the resident dry but with visible vaginal discharge. Instead of using a cleanser and wipes as per the facility's Incontinent Care policy, CNA #1 attempted to pick the dry discharge off the resident's vaginal area with their hands, causing discomfort to the resident. The Director of Nursing later confirmed that CNA #1's actions were substandard and indicated a need for further training.
Failure to Provide Showers for Residents
Penalty
Summary
The facility failed to provide showers for two residents who required assistance with activities of daily living. Resident #5, diagnosed with COPD and Parkinson's disease, reported not having had a shower in over a week and feeling dirty. The resident mentioned that staff cited insufficient staffing as the reason for not receiving showers. Similarly, Resident #6 stated they had not received a shower in over a week and only received one when they had a doctor's appointment. Interviews with CNAs revealed that they often ran out of time to complete baths and that documentation for showers was inconsistent, with showers being documented as completed when they were not. The Director of Nursing acknowledged the issue and mentioned they were in the process of hiring bath aides to address the problem.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, as documented in various reports and interviews. The Resident Council Minutes from January and February 2024 highlighted concerns about call lights not being answered or taking too long to be addressed. Additionally, the Grievance/Missing Property Monthly Tracking Log from March 2024 noted similar issues. A Device Activity Report from early June 2024 recorded multiple instances where call lights were activated for extended periods, ranging from 23 to 60 minutes, indicating a pattern of delayed responses. Interviews with residents and staff further corroborated these findings. Residents reported waiting times of up to an hour for call lights to be answered, with one resident experiencing a colostomy bag burst due to the delay. Staff members, including CNAs and LPNs, acknowledged that call lights should be answered within 5 to 10 minutes, yet there was no written policy in place to enforce this standard. The Director of Nursing confirmed the absence of a formal policy, stating that it is everyone's responsibility to answer call lights promptly.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration. On June 19, 2024, at 10:20 a.m., a Certified Medication Aide (CMA) was observed using bare fingers to break a potassium pill in half before administering it to a resident. The CMA acknowledged that gloves and a pill cutter should have been used during this process.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Tulsa Nursing Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Emerald Care Center Tulsa | 1.4 mi | ★★★★★ | 4 | 0 |
| Gracewood Health & Rehab | 2.8 mi | ★★★★★ | 9 | 0 |
| Trinity Woods, Inc. | 3.8 mi | ★★★★★ | 0 | 0 |
| Tulsa Center For Rehabilitation And Healthcare | 4.3 mi | ★★★★★ | 8 | 0 |
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