Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Tulsa Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
An LPN was observed standing while assisting a resident with the noon meal, despite the resident being dependent on staff for eating and having moderate cognitive impairment. The LPN and DON stated staff should be seated next to residents during meal assistance to maintain dignity, and the administrator identified eight residents dependent on staff for eating.
A resident with an indwelling urinary catheter was transferred from bed to wheelchair using a mechanical lift, and the CNA placed the catheter drainage bag on the floor, ran over it with the lift wheel, and slid it along the floor. The resident had intact cognition and was dependent on staff for transfers. The CNA, LPN, and DON all stated catheter drainage bags should be kept off the floor.
A facility failed to ensure working call lights were available for several residents, including a resident who said the call light had not worked for weeks. Surveyors observed call lights showing as active in the hallway, a missing call box with bare wires exposed, and a call box check log documenting missing boxes. A CNA and the DON acknowledged ongoing call light problems, and the DON stated residents were given whistles or bells if their call lights did not work.
A resident with dementia, mood and conduct disorders, and a history of aggressive and verbally abusive behaviors, including racial slurs, was involved in an altercation with a CNA in a common area. After the resident threw a soda or drink toward the CNA, the CNA immediately retaliated by throwing the drink or can back into the resident’s face and then walked away using explicit language about the resident. Witness statements, the incident report, and the resident’s documented behavioral history showed that the staff member’s retaliatory action constituted abuse, demonstrating a failure to protect the resident from staff abuse as required by facility policy.
A resident with multiple cardiac and vascular conditions was not weighed daily as ordered after hospital discharge, despite protocols for monitoring fluid overload. The omission of daily weights and lack of care plan interventions led to unmonitored weight gain and worsening edema, resulting in the resident's rehospitalization for CHF exacerbation. Staff interviews confirmed that daily weights were expected but not performed due to documentation and communication lapses.
A green capsule in a medication cup was found left unattended on top of a medication cart in the Southeast Hallway. An LPN stated they had intended to administer the medication to a resident but forgot, leaving it unsecured and accessible, contrary to facility policy requiring medications to be secured and accessible only to authorized personnel.
A resident with diabetes mellitus was receiving ordered Lantus insulin and had a standing physician order for HbA1c testing every three months to monitor blood glucose control. Facility policy required that ordered labs be provided or obtained. Review of records showed that all ordered HbA1c tests were completed except for one scheduled in February, which was missing from the chart. The administrator and ADON acknowledged there was no HbA1c result for that month; the ADON reported they had assumed the contracted dialysis company would perform the test and therefore the facility did not collect the blood sample, resulting in the ordered HbA1c not being obtained until the next scheduled test in May.
A resident requiring enhanced barrier precautions for tracheostomy care received care from an LPN who did not follow the facility’s hand hygiene and PPE protocols. The LPN left the room to obtain missing supplies, returned and donned a gown and gloves without performing hand hygiene, and later changed to sterile gloves without sanitizing hands between glove changes. The LPN cleaned the tracheostomy site and inner cannula, removed and replaced the trach collar, handled a pen from a uniform pocket to label the new collar, and completed the procedure without changing gloves appropriately or performing required hand hygiene steps, contrary to the facility’s hand hygiene policy and the DON’s stated expectations.
A facility failed to report an abuse allegation involving a resident with quadriplegia and generalized anxiety disorder to the OSDH within the required two-hour timeframe. The incident, which involved a physical altercation with the resident's significant other, occurred around midnight, but was not reported until the afternoon, exceeding the mandated reporting period.
A resident with dementia and a left leg amputation suffered a right knee abrasion when staff assisted with a transfer without using a gait belt, contrary to facility standards.
The facility failed to provide alternative meals due to insufficient dietary staff. Multiple residents reported that their requests for alternative meals were often denied or limited to peanut butter and jelly sandwiches. The CDM and Administrator confirmed that staff shortages led to this issue.
The facility failed to provide alternative meals as listed on the menu, often offering only peanut butter and jelly sandwiches due to staffing issues. This affected the nutritional needs and meal satisfaction of the residents.
The facility failed to ensure a timely transmission of an assessment for a resident who had expired. The Death In Facility assessment remained 'In Progress' and was not submitted within the required timeframe due to an unresolved warning that was not caught during the double-check procedure.
A resident with epilepsy did not receive scheduled doses of phenobarbital and phenytoin sodium due to medication unavailability, leading to seizures and hospitalization. The facility's policy to reorder medications in advance was not followed, resulting in a gap in treatment.
The facility failed to ensure a shower stall and curtain were clean in the southeast shower room. Observations revealed hard water stains, a black substance in the grout, and stained shower curtains. Despite daily cleaning claims, the issues persisted, and the housekeeping supervisor was unaware of the process for cleaning shower curtains.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain dignity while assisting a resident with meals. On 05/14/26 at 12:30 p.m., an LPN was observed standing while helping Resident #2 with the noon meal. A quarterly assessment dated 04/22/26 showed the resident had a BIMS score of 10, indicating moderate cognitive impairment, and that the resident was dependent on staff for eating. During interviews later that day, the LPN stated staff should sit while assisting residents with eating to maintain dignity when dining, and the DON stated staff should be seated next to the resident they were assisting to ensure dignity with dining. The administrator identified eight residents who were dependent on staff for eating.
Improper Handling of Catheter Drainage Bag During Transfer
Penalty
Summary
The facility failed to maintain infection control for a resident with an indwelling urinary catheter. During an observed transfer from bed to wheelchair using a mechanical lift, CNA #3 placed the catheter drainage bag on the floor, ran over it with the wheel of the mechanical lift, and then slid the bag along the floor from the front of the wheelchair to the back of the wheelchair. Resident #5 had an annual assessment showing a BIMS score of 15, indicating intact cognition, and was documented as having an indwelling urinary catheter and being dependent on staff for transfer from bed to chair. CNA #3 stated catheter bags should not be placed on the floor, LPN #3 stated catheter drainage bags should not be placed on the floor, slid along the floor, or run over with the wheel of the mechanical lift, and the DON stated catheter drainage bags should always be kept off the floor.
Nonfunctioning resident call light system
Penalty
Summary
The facility failed to ensure that a working call light system was available in residents’ bathrooms and bathing areas, with the deficiency identified for 3 of 5 sampled residents reviewed for functioning call lights. During observation, call lights in two rooms were seen on in the hallway, and the call light alert box at the nurses’ station showed the cord was out for those rooms. In another room, the call light box was missing entirely, and bare wires were observed hanging from the wall where it had been located. A call box check log also documented rooms with missing call light boxes. Resident #6 stated that the call light did not work and had been having issues for several weeks. A CNA stated they knew two rooms’ call lights did not work, but were not aware that the call lights in two other rooms did not work and were not sure whether those residents had another way to let staff know they needed something. The maintenance supervisor stated there had been ongoing issues with call light boxes requiring repairs and replacements, with several boxes missing. The DON stated there were ongoing issues with call lights and that residents were provided whistles or bells if their call lights did not work, but was not sure which lights were not working.
Staff-to-Resident Abuse Following Behavioral Outburst
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by staff. Facility policy on abuse and neglect required staff to identify, assess, care-plan, and monitor residents with behaviors that might lead to conflict, including those with aggressive behaviors, self-injurious behaviors, communication disorders, or total dependence on staff, and to monitor for early warning signs or changes that could trigger abusive behavior. The resident involved had diagnoses including violent behavior, dementia, depression, mood disorder, anxiety, and conduct disorder. A care plan and quarterly assessment documented that the resident was moderately impaired for daily decision-making and had the potential to demonstrate behaviors such as yelling out, swinging at staff and residents, cussing, and making racial slurs toward staff. An incident report documented that the resident threw soda on a CNA, who then threw a drink back into the resident’s face. A receptionist who witnessed the event stated the resident, seated near the CNA in a common room, suddenly threw a can of soda at the CNA, and the CNA immediately jumped up and threw the soda can back into the resident’s face, then walked down the hall saying staff should “get” the resident and using explicit language. The incident was reported to the administrator. In a later phone interview, the CNA stated the resident had called them racial names and thrown a drink that hit a bowl in the CNA’s hand, spilling drinks on the table and splashing on the resident, which led the resident to yell that the CNA had thrown a drink at them. The resident later stated they had not had a staff member throw a drink at them or abuse them. Despite these differing accounts, the documented staff action of throwing a drink back at the resident constituted abuse and demonstrated the facility’s failure to ensure the resident was free from abuse.
Failure to Obtain Daily Weights as Ordered for Resident with Fluid Overload Risk
Penalty
Summary
The facility failed to obtain daily weights for a resident as ordered by the physician following a hospital discharge. The resident, who had a history of coronary artery disease, hypertension, peripheral vascular disease, respiratory failure, ischemic cardiomyopathy, and a prior coronary artery bypass graft, was readmitted from the hospital with instructions to be weighed daily and to notify the physician if there was a weight gain of three pounds or more in 48 hours. Despite these orders, daily weights were not recorded in the electronic health record for the remainder of September or throughout October. The care plan did not include interventions for daily weights or fluid restriction, and the October active orders did not reflect the need for daily weights. The resident experienced significant weight gain and worsening edema, ultimately requiring hospitalization for congestive heart failure exacerbation. Interviews with facility staff revealed that the protocol for monitoring fluid overload included daily weights, especially for residents with CHF or noted edema. However, the DON stated that daily weights were not obtained because the resident was not identified as having CHF in the facility records, and the APRN acknowledged that weights should have been obtained but were not. The lack of adherence to physician orders and facility protocols contributed to the failure to monitor the resident's fluid status appropriately.
Unattended Medication Left on Cart
Penalty
Summary
A medication security deficiency occurred when a green capsule in a plastic medication cup was observed left unattended on top of a medication cart in the Southeast Hallway. The medication cart was not attended by staff at the time of observation. According to facility policy, medications are to be accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. An LPN later confirmed they had left the medication on top of the cart with the intention to administer it to a resident but forgot, acknowledging that the medication should have been secured inside the cart and not left unattended.
Failure to Obtain Ordered A1C Monitoring for Diabetic Resident
Penalty
Summary
A resident with a diagnosis of diabetes mellitus had a physician’s order for Lantus Solostar insulin, 5 units in the morning and 27 units in the afternoon, and a standing laboratory order for hemoglobin A1C testing every February, May, August, and November to monitor average blood glucose levels. Facility policy required that laboratory services be provided or obtained when ordered by a physician or other authorized practitioner. During record review, surveyors requested the resident’s A1C results and the administrator reported that, after searching the record, there were no A1C results for February 2025. The ADON confirmed that A1C results were present for all ordered months except February 2025. The ADON stated they had spoken with the contracted dialysis company that month and believed the dialysis staff would perform the A1C test, and therefore the facility did not collect the blood sample for testing. As a result, the ordered A1C test for February 2025 was not obtained, and the resident’s A1C was not tested again until May 2025, contrary to the physician’s lab order and the facility’s laboratory services policy.
Failure to Follow Hand Hygiene and PPE Protocols During Tracheostomy Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control protocols during tracheostomy care for one resident who had a physician order for enhanced barrier precautions related to tracheostomy care. During an observation of tracheostomy care, an LPN began the procedure and then discovered that needed supplies were not available in the resident’s room. The LPN removed their gloves and gown and left the room to obtain supplies. When the LPN returned with the supplies, they donned a gown and gloves in the room but were not observed to perform hand hygiene before putting on the new PPE. During the continuation of the tracheostomy care, the LPN opened a pair of sterile gloves, removed the existing gloves, and donned the sterile gloves without performing hand hygiene between glove changes. The LPN then opened supplies, used an alcohol wipe to clean the inner cannula, cleaned the area around the tracheostomy site, and placed the inner cannula without changing gloves between cleaning the site and inserting the cannula. While still wearing the same gloves, the LPN removed the old collar, cleaned the area around the site, opened a new collar, took a pen from a uniform pocket to label the collar, placed the new collar, gathered trash, and left the room. The facility’s hand hygiene policy required hand sanitizing before applying and after removing PPE, before and after handling clean or soiled dressings, and after handling items potentially contaminated with blood or bodily fluids. The DON stated that hand washing or sanitizing should occur before starting a procedure, between glove changes, and when the procedure was over.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe for one of the four sampled residents reviewed for abuse. The facility's policy on Abuse, Neglect, and Exploitation, revised in October 2023, mandates that alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. Resident #4, who had diagnoses including quadriplegia and generalized anxiety disorder, was involved in a physical altercation with their significant other in their room around midnight on August 10, 2024, prompting a police call. However, the incident was not reported to the OSDH until 4:13 p.m. on the same day, exceeding the two-hour reporting requirement. The facility administrator confirmed that allegations of abuse should be reported to the OSDH within two hours.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to use a gait belt during a transfer for one of the residents sampled for assistance with transfers. The resident involved had diagnoses including dementia and an amputation of the left lower leg. An incident occurred on 09/24/24, where staff assisted the resident with a transfer without using a gait belt, resulting in the resident suffering a right knee abrasion.
Insufficient Dietary Staff for Alternative Meals
Penalty
Summary
The facility failed to ensure sufficient dietary staff to provide alternative meals to residents. The facility had an alternative menu that included various options such as loaded baked potatoes, chef salad, and different types of sandwiches. However, observations and interviews revealed that residents were often told that only peanut butter and jelly sandwiches were available as alternatives due to staff shortages. This was confirmed by multiple residents who reported that their requests for alternative meals were frequently denied or limited to peanut butter and jelly sandwiches. The Certified Dietary Manager (CDM) and the Administrator both acknowledged that the lack of sufficient dietary staff led to the limited availability of alternative meals. The dietary schedules from late February to mid-March showed a reduction in the number of scheduled employees, with as few as three employees on some days. The CDM stated that seven people were needed daily to be adequately staffed. The Administrator and CDM both confirmed that the facility had been short-staffed recently due to personal reasons affecting dietary staff members. This staffing issue directly impacted the facility's ability to provide the alternative meals listed on the menu, leading to the deficiency noted in the report.
Failure to Provide Alternative Meals
Penalty
Summary
The facility failed to ensure alternative meals were provided for three residents reviewed for meal service. The facility's alternative menu listed various options such as loaded baked potatoes, chef salad, and different types of sandwiches. However, residents reported that dietary staff often stated they could not cook any alternatives or only offered peanut butter and jelly sandwiches. This was corroborated by multiple residents who confirmed the limited availability of alternative meals. On one occasion, a resident asked the Certified Dietary Manager (CDM) why alternative meals were not provided as ordered, and the CDM admitted that when there weren't enough staff, the alternative meals were limited. The Administrator confirmed that the facility did not have a policy regarding meal alternatives and acknowledged that only peanut butter and jelly sandwiches had been offered recently. This deficiency affected the nutritional needs and meal satisfaction of the residents involved.
Failure to Timely Transmit Resident Assessment
Penalty
Summary
The facility failed to ensure a timely transmission of an assessment for a resident who had expired. The resident's Death In Facility assessment was documented as 'In Progress' and had not been submitted within the required timeframe. The MDS Coordinator acknowledged that assessments are usually double-checked at the end of each month and typically completed within 48 hours. However, the assessment for this resident remained incomplete due to an unresolved warning, which was not caught during the double-check procedure. This resulted in the assessment not being submitted timely.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident diagnosed with epilepsy. The resident was supposed to receive phenobarbital 64.8 mg and phenytoin sodium 200 mg as part of their treatment plan. However, the medication administration record indicated that the resident did not receive the scheduled doses of phenobarbital on one occasion because the medication was not available. Additionally, the resident missed both the AM and PM doses of phenytoin sodium on another day due to the same issue of unavailability. This lapse in medication administration led to the resident experiencing two seizures and being sent to the hospital, where they were diagnosed with seizure-like activity and given a new order for phenytoin sodium 200 mg twice a day, which was their current dose at the time of the incident. The facility's policy on medication ordering and receiving from the pharmacy stated that medications should be reordered four days in advance to ensure an adequate supply. Despite this policy, the resident ran out of phenobarbital, and the medication was not reordered in time, resulting in a gap in treatment. Interviews with the Certified Medication Aide (CMA) and the Assistant Director of Nursing (ADON) confirmed that the medications were not administered as ordered, leading to the resident's hospitalization and subsequent return to the facility with a new medication order.
Failure to Maintain Clean Shower Facilities
Penalty
Summary
The facility failed to ensure a shower stall and curtain were clean in the southeast shower room. During an observation, the middle shower stall, which was the only one with a shower curtain, had hard water stains on the walls and a black substance in the grout on the floor next to the wall. The shower curtain had brown and orange stains scattered from top to bottom. The black substance was able to be scratched off, indicating it was not a permanent stain. Housekeeper #1 confirmed that shower rooms were cleaned every day, but the same issues were observed three days later. The housekeeping supervisor stated that shower rooms should be cleaned daily and monitored two to three times a day but was unaware of the process for ensuring shower curtains were cleaned. She acknowledged that the room had not been adequately cleaned despite the observations made on two separate occasions.
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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) |
|---|---|---|---|---|
| Montereau, Inc. | 0.7 mi | ★★★★★ | 7 | 0 |
| Southern Hills Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| The Cottage Extended Care | 1.9 mi | ★★★★★ | 0 | 0 |
| Gracewood Health & Rehab | 2.5 mi | ★★★★★ | 9 | 0 |
| The Villages At Southern Hills | 2.9 mi | ★★★★★ | 0 | 0 |
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