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 Oklahoma Memory Care Institute during CMS and state inspections, most recent first.
Multiple cognitively impaired residents experienced abuse or suspected abuse when one resident was found on the floor in a room with another resident pulling at their pants and partially exposing their underwear behind a makeshift barricade; in a separate case, a resident who was usually cheerful became tense and frightened, later found with fingertip‑sized bruises and crescent‑shaped skin tears after a CMA overheard two CNAs speaking about the resident in a derogatory manner; and in another incident, a CNA reported seeing a coworker strike a resident’s arm/hand several times after being hit by the resident, while the accused CNA described the contact as tapping in response to being grabbed, all occurring despite an abuse‑prevention policy.
The facility failed to follow its Abuse, Neglect and Exploitation policy requiring background checks for contracted staff by not screening a personal care worker privately hired by a family to provide care and companionship to a resident. The aide had been caring for the resident for several years and continued after the resident’s admission, but no background check was completed. The DON reported not realizing that a background check was required for a family-contracted caregiver, and a corporate nurse confirmed that the facility had not followed the screening portion of its policy.
A resident with dementia eloped from the facility due to inadequate supervision. The resident, severely impaired in decision-making, left through an unsecured window and was later found at a convenience store. The facility failed to conduct necessary rounds, leading to the resident's undetected departure.
A facility failed to report injuries of unknown origin for a resident with vascular dementia and frequent falls. Despite incident reports documenting bruising on two occasions, these were not reported to the state. The DON acknowledged the oversight, unable to locate the required state reports, while a later injury was reported, showing inconsistency in reporting practices.
The facility failed to maintain resident dignity by not addressing residents by their preferred names and by standing while assisting residents during meals. Staff used terms like 'grandma' and 'momma' instead of preferred names for residents with Alzheimer's or dementia. Additionally, the DON and ADON were observed standing while feeding dependent residents, contrary to the facility's policy to sit during mealtimes to ensure dignity.
The facility failed to ensure safe mechanical lift transfers for two residents, both requiring two staff members as per their care plans. One resident with dementia and heart failure was transferred by a single CNA, and another with Alzheimer's was similarly transferred, despite repeated in-service training for staff on the requirement for two-person assistance.
The facility failed to date opened insulin vials, pens, and glucose check strips on a medication cart. An LPN was unable to provide opening dates for these items, which were intended for multiple residents. The DON confirmed that staff were required to date these items upon opening, and that medication carts were monitored monthly by the pharmacy consultant.
The facility did not maintain documentation of COVID-19 vaccine education for staff, as required by their policy. During a review, it was found that there was no documentation for two CNAs regarding their education on the COVID-19 vaccination. The administrator confirmed that while discussions occurred during orientation, no records were kept.
A resident with dementia was inaccurately assessed regarding their medication regimen. The admission assessment incorrectly documented the resident as being on an anticoagulant, while they were actually on Plavix, an antiplatelet medication. The MDS coordinator admitted to the coding error, and the DON confirmed that the corporate office reviewed the assessments for accuracy.
A facility failed to monitor a resident with COPD during nebulizer treatments. The resident had orders for ipratropium-albuterol every six hours, but staff did not ensure the full treatment was administered. A CNA turned off the nebulizer prematurely, and an LPN left the resident unattended with the mask on, leading to uncertainty about the medication received. The DON confirmed that staff should stay with residents during treatments.
A resident with Alzheimer's and a history of falls was inaccurately assessed for bed rail safety, with the evaluation incorrectly noting no cognitive or balance issues. The ADON based assessments on limited observations, and the DON admitted the assessment was inaccurate. Maintenance staff failed to perform regular safety checks, leading to a gap between the mattress and bed rail, contrary to facility policy.
The facility failed to maintain infection control during meal times. The DON and ADON were observed assisting residents with meals without sanitizing their hands after touching food items directly. The DON later confirmed that staff should not touch residents' food or straws with bare hands.
A facility failed to monitor and maintain bed rails for a resident with Alzheimer's and dementia, despite a policy requiring proper use and maintenance. The Director of Maintenance only checked bed rails when informed of issues, leading to a significant gap between the mattress and bed rail, compromising safety.
The facility failed to provide financial quarterly statements for four residents with dementia who had monies deposited in the facility's resident trust. The BOM, new to their position, forgot to issue the required statements, resulting in no accounting of the residents' funds being provided.
A resident with gout did not receive necessary toenail care despite multiple indications in their records. The facility's staff, including a CMA and an LPN, acknowledged the resident's toenails were long and irregularly shaped but lacked the tools and knowledge to address the issue. A podiatrist visit was canceled due to a viral outbreak, and the resident transferred before receiving care. The DON confirmed the lack of documentation for toenail care.
Failure to Prevent Resident‑to‑Resident Sexual Incident and Staff Physical/Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to maintain an abuse‑free environment for multiple cognitively impaired residents. Facility policy on abuse, neglect, and exploitation required written procedures to prohibit and prevent abuse and to establish a safe environment, including for residents’ consensual sexual relationships and prevention of sexual abuse. Despite this, one resident with severe cognitive impairment and wheelchair dependence was found on the floor in another resident’s room, with that other resident sitting on the bed and holding the waistband of the resident’s pants and pulling downward, exposing the edge of the underwear. The doorway was partially blocked by a wheelchair, and other equipment was arranged in a crescent shape around the resident on the floor, and the resident was initially anxious. Staff reported that the resident who was pulling at the clothing was confused and did not know where they were or what they had done. Another incident involved a resident with a BIMS score of 0, indicating severe cognitive impairment and complete dependence in ADLs. A CMA reported overhearing two CNAs in this resident’s room referring to the resident in a derogatory manner. When the CMA entered the room shortly afterward, the CNAs were gone, and the resident, who usually laughed when the CMA entered, was instead tense, with their back straight and arms drawn tightly into the body. The CMA asked if the CNAs had hurt the resident, and the resident, who was rarely verbal but sometimes gave one‑ or two‑word responses, answered yes. Subsequent nursing assessment documented that the resident appeared frightened, with several small, round bruises approximately one to two centimeters in size and two crescent‑shaped skin tears on the right forearm, similar in size and shape to fingernails. A third incident involved another resident with severe cognitive impairment and dependence in ADLs. A state reportable incident documented that one CNA stated they witnessed another CNA “pop” the resident on the arm/hand after the resident hit the CNA following a change. The CNA accused of striking the resident stated they had only tapped the resident on the wrist four times because the resident allegedly grabbed them by the waist and chest. These events, involving physical and verbal mistreatment and an attempted removal of clothing from a cognitively impaired resident, occurred despite the facility’s written policy prohibiting abuse and requiring prevention of abuse, neglect, and exploitation.
Failure to Conduct Required Background Check on Private Caregiver
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy requiring background, reference, and credentials checks for potential employees, contracted temporary staff, students, volunteers, and consultants by not performing a background check on a personal care worker (PCW #1) who was providing care to a resident. The policy, implemented in 01/2026, specified that such screening was to be conducted on all categories listed, but record review and interviews showed that no background check had been completed for PCW #1. PCW #1 reported being a home health aide contracted by the family of Resident #5 to provide care and companionship and had continued in this role after the resident moved into the facility in 09/2025. The DON stated they were unaware that the facility was required to perform a background check on an individual contracted by a family to provide care to a specific resident and doubted that any check had been done, and the corporate nurse confirmed that the facility had not performed a background check on PCW #1 and acknowledged that the screening portion of the policy had not been followed. This deficiency centers on the facility’s inaction in implementing its own abuse-prevention screening requirements for an individual providing direct care and company to a resident under a private arrangement with the family, despite the clear policy language that encompassed contracted staff.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to supervise and prevent a resident from eloping, which led to a past noncompliance Immediate Jeopardy situation. The resident, who had a diagnosis of dementia and was severely impaired in daily decision-making, managed to leave the facility undetected. On the evening of January 29, 2025, the resident barricaded their door with a chair, and by the following morning, the facility received a call from a local hospital regarding the resident's whereabouts. An investigation revealed that the resident was last seen in the facility the previous night, and their room's window was found open with the screen removed. The resident was discovered at a convenience store and transported to a local hospital by ambulance, where they were found uninjured. The resident was returned to the facility and placed under continuous supervision. The incident highlighted the facility's failure to provide adequate supervision to prevent elopement, as the staff did not conduct the necessary rounds to monitor the resident's whereabouts. The deficiency was identified for one of the three sampled residents reviewed for supervision.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin to the required state agencies for one of the three sampled residents reviewed for such injuries. The resident in question had diagnoses including vascular dementia, anxiety, and frequent falls. Incident reports revealed two instances of injuries of unknown origin, with bruising noted on the temple and right upper thigh on two separate occasions. However, these incidents were not reported to the state, as confirmed by the absence of state reports for these dates. The Director of Nursing (DON) acknowledged the oversight, stating that they were unable to locate the state reports for these incidents and did not know why they were not completed. The facility did report a later injury involving a right subcapital femoral neck fracture to the state, indicating inconsistency in reporting practices.
Failure to Maintain Resident Dignity in Address and Dining
Penalty
Summary
The facility failed to ensure residents were treated with dignity by not addressing them by their preferred names and by not maintaining dignity during mealtimes. Specifically, three residents with Alzheimer's disease or dementia were not called by their preferred names as outlined in their care plans. Instead, staff members used terms like 'grandma' and 'momma,' which were not requested by the residents. This was acknowledged by the staff, including a CNA and an LPN, who admitted to using these terms as habits or terms of endearment, despite knowing the residents' preferred names. Additionally, the facility did not maintain dignity during dining for several residents who were dependent on staff for meals. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were observed standing while assisting residents with meals, contrary to the facility's policy that staff should be seated while feeding residents to promote dignity. The DON acknowledged the issue, citing the size of wheelchairs and geri chairs as a reason for not sitting, but confirmed that staff should sit to maintain residents' dignity during meals.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers for two residents, both of whom required assistance from two staff members according to their care plans. Resident #21, diagnosed with dementia, anxiety, and heart failure, was observed being transferred by a single CNA using a mechanical lift, contrary to the care plan initiated on 02/28/24, which required two staff members. The CNA admitted to transferring the resident alone because the resident requested it, despite the care plan's stipulations. Similarly, Resident #18, with Alzheimer's and dementia, was also transferred by a single CNA using a mechanical lift, despite the care plan initiated on 12/29/23, which required two staff members for transfers. The DON acknowledged that two staff members were required for all mechanical lift transfers and noted that staff had been repeatedly in-serviced on this requirement, but the training had not been effective in changing staff behavior.
Failure to Date Opened Insulin and Glucose Strips
Penalty
Summary
The facility failed to ensure that insulin was dated when opened on one of the two medication carts observed for medication storage. During an observation, it was noted that several insulin vials and pens, as well as glucose check strips, were opened and not dated on treatment cart #1. The medications involved included a Lantus insulin vial, Fiasp flex touch pen, insulin aspart pens, Basaglar pen, and Levemir pen, which were intended for multiple residents. LPN #1, who was present during the observation, was unable to provide the dates when these items were opened. The Director of Nursing (DON) confirmed that staff were required to date insulin and glucose check strips upon opening and that medication/treatment carts were monitored monthly by the pharmacy consultant.
Failure to Document COVID-19 Vaccine Education for Staff
Penalty
Summary
The facility failed to maintain documentation that staff were educated and offered the COVID-19 vaccine, as required by their policy dated 06/27/23. This deficiency was identified during a record review and interviews, where it was found that there was no documentation for two employees regarding their education on the COVID-19 vaccination. Specifically, the infection preventionist and the administrator confirmed the absence of documentation for CNA #2 and CNA #4, respectively. The administrator acknowledged that while discussions about the COVID-19 vaccination occurred during new employee orientation, no records of the education or information provided were maintained for any staff members.
Inaccurate Medication Assessment for a Resident
Penalty
Summary
The facility failed to ensure accurate assessments for a resident diagnosed with dementia. The admission assessment inaccurately documented that the resident was on an anticoagulant medication and not on an antiplatelet medication. However, a review of the physician orders revealed that the resident was actually on Plavix, an antiplatelet medication, and there was no documentation of an anticoagulant medication being ordered. The MDS coordinator acknowledged the error, stating that the medication was incorrectly coded as an anticoagulant instead of an antiplatelet medication. The Director of Nursing confirmed that the corporate office reviewed the assessments for accuracy.
Failure to Monitor Resident During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure proper monitoring of a resident during nebulizer treatments, as observed in the case of a resident with chronic obstructive pulmonary disease. The resident had a physician's order for ipratropium-albuterol to be inhaled every six hours. However, during an observation, a CNA was seen turning off the nebulizer machine and removing the mask without ensuring the resident had completed the treatment. On another occasion, an LPN administered the medication but left the room with the nebulizer mask still on the resident, who was later observed holding the mask away from their face. The LPN admitted to not knowing how much medication the resident had received and was informed only after the incident that they were required to stay with the resident throughout the treatment. The DON confirmed that nurses were expected to remain with residents during nebulizer treatments to ensure the full treatment was administered. This lack of supervision and monitoring during the nebulizer treatments led to the deficiency identified in the report.
Inaccurate Bed Rail Assessment and Maintenance Deficiency
Penalty
Summary
The facility failed to accurately assess a resident for the safe use of bed rails, leading to a deficiency in care. The resident, who had Alzheimer's disease, dementia, and a history of repeated falls, was identified as a high fall risk. Despite this, the Bed Rail/Assist Bar Evaluation inaccurately documented that the resident had no cognitive deficit and no balance issues. The Assistant Director of Nursing (ADON) admitted to making these assessments based on the resident's ability to sit up in a chair, without a thorough evaluation. The Director of Nursing (DON) acknowledged that the assessment was not accurate and had not been reviewed after completion. Additionally, the facility's maintenance staff did not perform regular safety checks on the bed rails, only addressing them if informed of looseness. An observation revealed a significant gap between the mattress and the bed rail, posing a potential safety hazard. The facility's policy required appropriate alternative approaches before using bed rails and ensuring their correct installation and maintenance, which was not adhered to in this case.
Infection Control Breach During Meal Assistance
Penalty
Summary
The facility failed to maintain proper infection control practices during meal times, as observed during two separate meals. The Director of Nursing (DON) was seen assisting four residents with their morning meal, during which they picked up a biscuit with jelly using their bare hands and placed it into a resident's mouth without sanitizing their hands. Similarly, during the noon meal, the Assistant Director of Nursing (ADON) assisted a resident with a drink by touching the straw and then continued to assist other residents without sanitizing their hands. Additionally, the DON was observed handing a dinner roll to a resident without sanitizing their hands. The DON later acknowledged that staff should not directly touch residents' food or straws with their bare hands.
Failure to Monitor and Maintain Bed Rails
Penalty
Summary
The facility failed to ensure ongoing monitoring and supervision of bed rails for a resident with Alzheimer's disease, dementia, and a history of repeated falls. The facility's policy on the proper use of bed rails required appropriate alternative approaches before installing or using bed rails and ensuring their correct installation, use, and maintenance. However, the Director of Maintenance admitted that they only checked the bed rails if informed they were loose, rather than performing regular safety checks. During an observation, a significant gap was noted between the mattress and the bed rail on the resident's bed, indicating improper installation or maintenance.
Failure to Provide Financial Statements for Residents' Trust Accounts
Penalty
Summary
The facility failed to provide financial quarterly statements for four residents who had monies deposited in the facility's resident trust. The trust account balance statement, dated 10/15/24, documented that these residents, all diagnosed with dementia, had funds deposited in the facility trust. During an interview on 10/16/24, the Business Office Manager (BOM) admitted to being somewhat new to their position and acknowledged forgetting to provide the required quarterly financial statements to the residents and/or their representatives. As a result, none of the residents with funds in the resident trust received an accounting of their monies.
Failure to Provide Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for a resident who was admitted with a diagnosis of gout and required assistance with bathing and hygiene. The resident's clinical records indicated that toenail care was needed on multiple occasions, as documented in shower sheets dated from August to September. Despite these records, there was no documentation that toenail care was provided. A Certified Medication Aide (CMA) observed the resident's toenails to be long, thick, and irregularly shaped, and admitted to not knowing how to cut them. The Licensed Practical Nurse (LPN) also confirmed the condition of the toenails and expressed discomfort in cutting them due to a lack of appropriate tools and knowledge on where to document such care in the electronic medical record. The facility's social service director stated that the podiatrist, who was responsible for trimming toenails, visited every three months but the visit was canceled due to a viral outbreak. Consequently, the resident was not seen by the podiatrist before transferring to another facility. The Director of Nursing (DON) acknowledged that the resident's toenails should have been cut and confirmed the absence of documentation for toenail care in the resident's clinical record.
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Illustrative
What surveyors actually found near you
We read the 117 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
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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) |
|---|---|---|---|---|
| Trinity Woods, Inc. | 0.6 mi | ★★★★★ | 0 | 0 |
| Gracewood Health & Rehab | 1.9 mi | ★★★★★ | 9 | 0 |
| Southern Hills Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Colonial Manor Nursing Home | 2.7 mi | ★★★★★ | 2 | 0 |
| Emerald Care Center Tulsa | 3 mi | ★★★★★ | 4 | 0 |
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