Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Woods, Inc. during CMS and state inspections, most recent first.
The facility failed to maintain infection control practices in several areas. Staff were not fit tested annually for N95 respirators, an LPN/Household Manager handled resident medications with bare hands during med pass for multiple residents, and reusable vital sign equipment was used between residents without being disinfected. The residents involved had significant cognitive impairment and multiple chronic conditions, and the DON, IP, and staff interviews confirmed the lapses.
A resident with essential hypertension had an order to notify the physician if SBP was above 160 mm/Hg, but multiple elevated BP readings were not reported or documented. Staff interviews showed CMAs collected vitals, nurses were expected to notify the physician through an encrypted messaging system, and the Medical Director found no indication he had been informed of the abnormal readings.
A resident with aphasia, gastrostomy status, recurrent depressive disorder, and severe cognitive impairment remained on sertraline despite a pharmacy review and MD agreement to discontinue the antidepressant. Staff did not implement the discontinuation order, the medication stayed active in the system, and the resident continued receiving the drug on the TAR.
Infection control failures during respirator fit testing, medication handling, and vital sign equipment disinfection
Penalty
Summary
The facility failed to ensure staff were fit tested annually for N95 respirator masks. A facility COVID-19 guideline stated respirators should be used within a comprehensive respiratory protection program that includes medical evaluations, fit testing, and training in accordance with OSHA respiratory protection standards. CDC and NIOSH guidance in the report stated fit testing must be conducted annually and repeated whenever changes in an employee’s physical condition could affect respirator fit. During interviews, the Infection Preventionist stated she had been in the role for about 22 months and had not fit tested any staff, the Administrator stated the facility had not fit tested staff since the current Infection Preventionist began, and multiple staff members stated they had not been fit tested within the past year or at all during their time at the facility. The Administrator also stated the facility could not find a list of staff who had been fit tested. The facility also failed to maintain sanitary technique during medication administration for four residents. A medication administration policy required staff to follow infection control procedures such as hand washing, aseptic technique, and gloves when administering medications. During observation, Household Manager #6 removed oral medications from packaging and placed them into her ungloved hand before putting them into medication cups for administration to residents with significant cognitive impairment and multiple medical diagnoses, including dementia, heart failure, atrial fibrillation, chronic kidney disease, depression, and other chronic conditions. For one resident, the nurse removed medications from a multi-dose card into her ungloved hand; for another, a tablet fell onto the medication cart and was picked up with an ungloved hand before administration; and for two other residents, medications were similarly handled in the nurse’s bare hand before being given. The nurse stated she had been trained not to touch medications directly and acknowledged she should have donned a glove before touching them. The facility further failed to disinfect reusable vital sign equipment between residents. A standard precautions policy stated reusable equipment should not be used for another resident until appropriately cleaned and reprocessed. During observations, Household Manager #6 obtained blood pressure, pulse, oxygen saturation, and temperature readings for three residents using the same multi-resident device and did not clean the equipment before or after use. The residents observed had orders for routine vital signs and had severe cognitive impairment or other significant medical conditions. The Infection Preventionist and Director of Nursing both stated the equipment should have been disinfected between residents, and the Household Manager stated she had been trained to disinfect the equipment between residents but did not do so at the time.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to notify the physician when Resident #13’s systolic blood pressure was above the physician-ordered parameter of 160 mm/Hg. Resident #13 was admitted with a diagnosis of essential hypertension and had a BIMS score of 14, indicating the resident was cognitively intact. The care plan and active physician order both directed staff to notify the physician if systolic blood pressure exceeded 160 mm/Hg, and the facility policy stated hypertension should be reported to the physician. Record review showed 35 blood pressure readings from 05/10/2026 through 05/31/2026 with systolic values above 160 mm/Hg, including readings as high as 197/84 mm/Hg and 185/82 mm/Hg, with no documentation that the physician was notified. During interviews, a CMA stated elevated vital signs were verbally told to the nurse but not documented, and that the threshold for reporting Resident #13’s blood pressure had not been communicated to CMAs. An RN stated nurses notified the physician when systolic blood pressure was above 160 mm/Hg and documented the notification, but was unsure whether her notifications had been documented. The Medical Director stated he reviewed communications for Resident #13 and found no indication of elevated blood pressures and was not aware of the abnormal readings.
Failure to Implement Discontinuation Order for Sertraline
Penalty
Summary
The facility failed to implement a pharmacy recommendation to discontinue sertraline for one resident reviewed for unnecessary medications. The resident had a history of aphasia, gastrostomy status, and recurrent depressive disorder, and the quarterly MDS showed severe cognitive impairment with a BIMS score of 3. The resident’s care plan identified antidepressant use for depression and noted the last GDR for antidepressant medications was on 05/01/2023. The active order remained sertraline 12.5 mg via peg-tube daily for depression, and the resident continued to receive the medication in May and June 2026. The consultant pharmacist reviewed the resident’s psychotropic medication and asked the prescriber to determine whether sertraline was still needed or whether a trial discontinuance was an option. The MD agreed and wrote to discontinue the medication after a 7-day every-other-day taper, signing the response in December 2025. Facility staff, including the pharmacy consultant, MD, HM, DON, and Administrator, stated the order should have been implemented, but the medication order was not removed from the computer and the drug continued to be administered to nursing staff for ongoing administration.
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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.
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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) |
|---|---|---|---|---|
| Oklahoma Memory Care Institute | 0.6 mi | ★★★★★ | 2 | 0 |
| Gracewood Health & Rehab | 1.3 mi | ★★★★★ | 9 | 0 |
| Southern Hills Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Emerald Care Center Tulsa | 2.5 mi | ★★★★★ | 4 | 0 |
| Colonial Manor Nursing Home | 2.8 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 October 2026) and official state health department websites.