Above 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 Tulsa Nursing Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. Facility policy required targeted gown and glove use for high-contact care under EBP, and the resident had physician orders for catheter care every shift and placement on EBP. During an observation, two CNAs provided catheter care without wearing gowns. Both CNAs later acknowledged that gowns should have been used, and the DON confirmed that gowns are required for catheter care for residents on EBP. The resident, who was cognitively intact, reported that staff usually did not wear gowns during catheter care.
The facility failed to review and revise care plans after assessments for two residents. One resident with COPD had their care plan last reviewed months before a quarterly assessment, and the MDS coordinator could not explain the delay. Another resident with depression also had a care plan review lapse, with the MDS nurse unable to provide a reason. These deficiencies highlight a failure to follow care plan review protocols.
The facility failed to complete monthly medication regimen reviews for four residents, as required by policy. Despite the consultant pharmacist's assurance of monthly reviews, the DON could not locate the reports for specific months. The residents had various diagnoses and were on multiple medications, highlighting a lapse in monitoring and documentation.
A facility failed to complete a significant change assessment within 14 days for a resident who elected hospice services. The resident, diagnosed with dementia, was admitted to hospice, but the assessment was delayed beyond the required timeframe. The corporate MDS coordinator confirmed the oversight, and the DON acknowledged the late completion by the previous MDS coordinator.
The facility failed to ensure accurate assessments for two residents. One resident, with chronic obstructive pulmonary disease, was incorrectly documented as receiving anticoagulant medication, which was not administered. Another resident, with hypertension, experienced a significant weight loss that was not accurately reflected in their assessment. The discrepancies were confirmed by the DON and a corporate MDS coordinator, respectively.
A facility failed to obtain a physician order for an indwelling urinary catheter for a resident admitted with acute kidney failure. Although the admission assessment noted the catheter, the electronic clinical record lacked a physician order. The DON confirmed the resident's 10-day stay and the usual process for entering orders but could not explain the oversight.
A resident experienced significant weight loss, dropping from 185 to 166.6 pounds over five months, without appropriate intervention from the facility. Despite the resident's illness and lack of appetite, no one discussed the weight loss with them. The DON admitted to being aware of the weight loss through monthly reports but failed to address it, while the dietitian did not provide recommendations due to a pending re-weigh.
A resident with hemiplegia was unable to reach their call light on multiple occasions, as it was observed hanging down to the floor. The resident reported relying on their roommate for assistance. A CNA and an LPN acknowledged the responsibility to ensure call lights are within reach, but the issue persisted.
A resident with altered nutritional status experienced significant weight loss over five months, but the facility failed to notify the physician. Despite the resident's care plan including weight monitoring, the DON admitted the weight loss was not addressed, and the dietitian noted no recommendations were made. The resident reported unintentional weight loss due to illness and lack of appetite.
A facility failed to maintain narcotic records after a resident's discharge. The resident, who was prescribed oxycodone for pain management, was discharged with medications, but the quantity of oxycodone sent was not documented. The electronic clinical record lacked a controlled drug record for the oxycodone. Staff interviews revealed that controlled drug records were not filed as required, and audits to ensure record maintenance were infrequent.
Failure to Use Gowns During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during catheter care. The facility’s Infection Control policy dated 04/01/24 required targeted gown and glove use during high-contact resident care activities under EBP. Physician orders showed that Resident #7 had an indwelling catheter with catheter care ordered every shift as of 01/07/26 and was placed on EBP as of 01/16/26. A quarterly assessment dated 03/27/26 documented that Resident #7 had intact cognition, with a Brief Interview for Mental Status score of 15, and an indwelling catheter. On 04/29/26 at 11:03 a.m., CNA #1 and CNA #2 were observed providing catheter care to Resident #7 without wearing gowns, despite the resident being on EBP and the facility’s policy requiring gown use for such care. CNA #1 acknowledged that gowns should have been worn under EBP, and CNA #2 stated they had forgotten to put on a gown. Resident #7 reported that staff usually did not wear gowns during catheter care, and on 04/30/26 the DON confirmed that gowns should be worn when providing catheter care to residents on EBP.
Failure to Review and Revise Care Plans After Assessments
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised after each assessment for two residents. Resident #5, diagnosed with chronic obstructive pulmonary disease, had their care plan last reviewed on 09/11/24, despite a quarterly assessment being completed on 01/21/25. The corporate MDS coordinator acknowledged that the care plan was overdue for review and revision but could not explain the oversight. Similarly, Resident #18, who had a diagnosis of depression, had their care plan last reviewed on 12/04/24, even though a quarterly assessment was completed on 01/21/25. The MDS nurse confirmed that the care plan was not reviewed in January and could not provide a reason for this lapse. These deficiencies indicate a failure to adhere to the requirement of reviewing and revising care plans after each assessment.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were completed for four out of five sampled residents who were reviewed for unnecessary medications. The facility's policy required a consultant pharmacist to review each resident's medication regimen and medical chart monthly, with findings communicated to the Director of Nursing (DON) or designee and documented in the resident's chart. However, for Resident #2, no medication regimen reviews were found for April 2024 and December 2024. Similarly, Resident #69's records lacked reviews for February 2024, July 2024, November 2025, and February 2025. Resident #16 did not have reviews for April 2024 and August 2024, and Resident #66 was missing reviews for April 2024 and September 2024. Despite the consultant pharmacist's statement that they reviewed every resident's medication regimen monthly and submitted the reports to the facility, the DON could not locate the requested reviews for the specified months. The residents involved had various diagnoses, including depression, hypertension, diabetes, dementia, and schizoaffective disorder, and were receiving multiple medications such as antipsychotics, anticoagulants, hypoglycemics, antianxiety medications, and antidepressants. The absence of documented medication regimen reviews indicates a failure in the facility's process to ensure appropriate monitoring and documentation of residents' medication regimens.
Failure to Timely Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days for a resident who elected hospice services. The resident, diagnosed with dementia, received a physician's order on July 29, 2024, to be admitted to hospice for evaluation and treatment. However, the significant change assessment was not completed until August 21, 2024, which was beyond the required 14-day period. During an interview on March 12, 2025, the corporate MDS coordinator confirmed that the assessment should have been completed within the specified timeframe. The Director of Nursing reviewed the order and assessment and acknowledged that the previous MDS coordinator had completed the assessment late.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents. Resident #5, diagnosed with chronic obstructive pulmonary disease, was inaccurately documented as receiving anticoagulant medication in their quarterly assessment dated 01/21/25. However, a review of the January 2025 medication administration record revealed that the resident did not receive such medication. The Director of Nursing (DON) confirmed the discrepancy and noted that the MDS coordinator responsible for the assessment was no longer employed at the facility. Resident #18, diagnosed with hypertension, experienced a significant weight loss of 10.16% over a period of less than six months, dropping from 185 pounds to 166.2 pounds. Despite this, the quarterly assessment dated 01/21/25 failed to reflect the weight loss, although it did record the current weight as 166 pounds. The corporate MDS coordinator was unable to explain why the assessment did not accurately indicate the weight loss.
Failure to Obtain Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician order for an indwelling urinary catheter for a resident who was admitted with acute kidney failure. The admission assessment indicated the presence of the catheter, but the electronic clinical record lacked a corresponding physician order. The Director of Nursing (DON) acknowledged that the resident had been in the facility for approximately 10 days and that the responsibility for entering physician orders upon admission typically fell to the admissions nurse, assistant director of nursing, or the DON themselves. However, they were unable to explain why the order for the catheter had not been entered into the electronic clinical record.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address significant weight loss for a resident diagnosed with depression, gastro-esophageal reflux disease, and altered nutritional status. The resident's weight decreased from 185 pounds at admission to 166.6 pounds over five months, indicating a weight loss greater than 10%. Despite this, a quarterly assessment showed no concern for nutrition or weight loss. A follow-up nutrition note recorded the resident's weight at 159.9 pounds but included no recommendations. The care plan later identified a concern for diet, aiming to maintain the resident's weight, but did not effectively address the ongoing weight loss. Interviews revealed that the resident was not intentionally losing weight but had been ill and not eating, and no one had discussed the weight loss with them. The Director of Nursing (DON) acknowledged the oversight, stating that they were aware of weights through monthly reports but had not addressed the significant weight loss. The dietitian mentioned that no recommendations were made because a re-weigh was requested, indicating a lack of immediate action to address the resident's nutritional needs.
Call Light Inaccessibility for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident diagnosed with hemiplegia or hemiparesis, as outlined in their care plan. On two separate occasions, the call light was observed clipped to the resident's bedding and hanging down to the floor, making it inaccessible. The resident expressed that they sometimes could not reach the call light and had to rely on their roommate to call for help. A CNA acknowledged that it was their responsibility to ensure call lights were within reach but was unaware of why it was not accessible to the resident. An LPN confirmed that it was the CNAs' responsibility to place call lights within reach and that nurses should make rounds to ensure compliance.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss in a resident who was being monitored for nutrition and weight loss. The resident, who had a diagnosis of altered nutritional status, experienced a weight loss of more than 10% over five months. Despite this significant change, there was no documentation indicating that the physician had been informed. The resident's care plan included monitoring weight and dietary interventions, but these measures did not result in physician notification. The resident expressed that their weight loss was unintentional and related to illness and lack of appetite. The Director of Nursing (DON) acknowledged that the resident's weight loss should have been identified through monthly weight reports, but it was not addressed. The dietitian also noted that no recommendations were made, possibly due to a request for a re-weigh. This oversight in communication and documentation led to the deficiency identified in the report.
Failure to Maintain Narcotic Records Post-Discharge
Penalty
Summary
The facility failed to maintain narcotic records after the discharge of a resident who was prescribed oxycodone for pain management following joint replacement and osteoarthritis. A physician's order indicated the resident was to receive oxycodone 10mg-325mg every six hours as needed. Upon discharge, the interdisciplinary discharge summary noted that medications were sent with the resident, but it did not specify the quantity of oxycodone provided. Furthermore, the electronic clinical record lacked documentation of a controlled drug record or an accounting of the oxycodone sent with the resident. Interviews with facility staff revealed procedural lapses in handling controlled drug records. A CMA stated that upon a resident's discharge, medications were given to the nurse, and controlled drug records were supposed to be filed in the medication room for medical records staff. However, the DON acknowledged that the controlled drug record for the resident's oxycodone was not located and should have been filed in the electronic clinical record. The DON also admitted that audits to ensure the maintenance of controlled drug records were not conducted frequently enough.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 115 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) |
|---|---|---|---|---|
| Leisure Village Health Care Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Emerald Care Center Tulsa | 2.1 mi | ★★★★★ | 4 | 0 |
| Gracewood Health & Rehab | 3.7 mi | ★★★★★ | 9 | 0 |
| Trinity Woods, Inc. | 4.5 mi | ★★★★★ | 0 | 0 |
| Franciscan Villa | 4.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Tulsa Nursing Center.
100% money-back within 48 hours.
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.