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 University Village Retirement Community during CMS and state inspections, most recent first.
The facility failed to ensure meals were palatable and served at appropriate temperatures for residents. Observations showed that food temperatures were not consistently checked before serving, resulting in meals being served cold or not hot enough. Residents reported dissatisfaction with meal temperatures, and staff interviews confirmed that temperature checks were only done after cooking, not before serving.
The facility failed to maintain sanitary conditions in food service, with staff not adhering to proper hand hygiene and glove use protocols. Dietary aides and CNAs were observed handling food and interacting with residents without changing gloves or sanitizing hands, contrary to the facility's Food Handling policy. This affected 65 residents in two dining areas.
The facility's arbitration agreements failed to specify the use of a neutral arbitrator and a mutually convenient venue for dispute resolution. This issue was identified in the cases of three residents, with a total of 56 residents having signed similar agreements. The administrator was unaware of the omission in the agreement language.
A resident with obstructive and reflux uropathy did not receive privacy during catheter care, as required by facility policy. A CNA and an LPN provided care without closing the privacy curtain, despite the presence of the resident's roommate. Both staff members acknowledged the oversight, with the CNA not noticing the roommate and the LPN being in a rush. The DON confirmed the expectation to close privacy curtains during personal care.
The facility failed to secure medications in locked carts, as observed with two of the seven carts. A medication cart was found unlocked with no staff in view, and an RN was seen leaving a cart unlocked while attending to residents. The DON confirmed that carts should be locked when unattended.
A facility failed to accurately document medication side effects for a resident with anxiety, depression, and atrial fibrillation. Despite physician's orders to monitor and document side effects in progress notes, the Treatment Administration Records (TARs) showed multiple instances of side effects without corresponding documentation in the progress notes. Interviews revealed that staff misunderstood the documentation process, leading to inaccurate records.
The facility failed to include necessary language in arbitration agreements, omitting residents' rights to rescind within 30 days and clarifying that signing was not a condition for admission. This affected multiple residents with serious health conditions, and the administrator was unaware of the oversight.
The facility failed to prevent infection by not maintaining catheter tubing off the floor for two residents. One resident with an obstructive bladder was repeatedly observed with catheter tubing on the floor or fall mat. Another resident with a neurogenic bladder and a history of UTIs had tubing hanging below their wheelchair. Staff acknowledged the tubing should not be on the floor, indicating a lapse in infection control protocols.
A hospice-supplied bed was not inspected for safety before use, leading to an incident where a resident with a history of falling slid from the bed due to a headboard separation. The resident landed on their knees with their head resting against the mattress and bed rail, resulting in a small skin tear on their neck. The facility's policy required bed inspections prior to use, but maintenance staff did not inspect hospice-supplied beds.
Failure to Ensure Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure meals were palatable for three residents who were reviewed for food palatability. The Food and Nutrition Services policy, revised in October 2017, mandates that food should appear palatable and attractive and be served at a safe and appetizing temperature. However, observations revealed that food temperatures were not consistently checked before serving. On one occasion, food temperatures were taken when the food was cooked, but not before plating, resulting in carrots and green beans being served below the holding temperature at 128 degrees Fahrenheit. Residents reported that their meals were cold or not hot enough, indicating a failure to adhere to the policy. Further observations showed that staff did not consistently check food temperatures before serving. A test tray from the hall cart was found to be without flavor and not served at a palatable temperature. Staff interviews confirmed that food temperatures were only taken once the food was cooked and not before serving, which contributed to the deficiency. This lack of adherence to the facility's policy on food temperature checks led to meals being served at unsatisfactory temperatures, affecting the residents' dining experience.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was served in a sanitary manner in two dining areas, affecting 65 residents who ate in these areas. Observations revealed that a dietary aide (DA #1) used their gloved hand to guide ice into cups after touching multiple objects without changing gloves or sanitizing hands. Another dietary aide (DA #3) delivered meals without changing gloves or sanitizing hands, touching various surfaces and residents in between. Additionally, DA #3 did not wear a hair net while handling food in the kitchen. Certified Nursing Assistants (CNAs) were also observed not sanitizing their hands between tasks, such as repositioning residents and passing meal trays. The facility's Food Handling policy, revised in July 2014, emphasized minimizing the risk of foodborne illness, yet staff actions did not align with these standards. Interviews with staff revealed a lack of adherence to proper hand hygiene and glove use protocols. The Director of Nursing (DON) confirmed that staff were expected to pick up cups from the side and change gloves if they touched residents or other objects, which was not consistently practiced. This lack of compliance with sanitary procedures posed a risk of contamination and foodborne illness to the residents.
Arbitration Agreement Deficiency
Penalty
Summary
The facility failed to ensure that arbitration agreements included language specifying the use of a neutral arbitrator and a venue convenient for both parties. This deficiency was identified in the cases of three residents who had signed arbitration agreements as part of their admission packets. The agreements stipulated that disputes would be settled by arbitration conducted in Tulsa County, OK, according to the company's rules, without mentioning the requirement for a neutral arbitrator or a mutually convenient venue. The administrator, who was new to the facility, was unaware of why the agreements lacked this language. A total of 56 residents had signed similar arbitration agreements.
Failure to Ensure Privacy During Catheter Care
Penalty
Summary
The facility failed to ensure privacy during urinary catheter care for a resident with obstructive and reflux uropathy. The facility's policy, dated August 2022, required staff to provide privacy during catheter care. However, during an observation on December 4, 2024, a CNA and an LPN were seen providing catheter care to the resident without closing the privacy curtain, despite the presence of the resident's roommate in the room. Both the CNA and LPN acknowledged the oversight, with the CNA stating they did not notice the roommate and the LPN admitting they were in a rush and failed to close the curtain. The Director of Nursing confirmed that staff were expected to close privacy curtains during personal care.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure medications were secured in locked medication carts, as observed with two of the seven medication carts. On December 3, 2024, at 3:08 p.m., medication cart #1 on Bluebird Hall was found unlocked with no staff in view. Similarly, at 3:17 p.m., medication cart #2 was also observed unlocked in the hallway. RN #1 was seen removing medication from cart #1 and entering a room, leaving the cart unlocked. RN #2 moved cart #2 to several rooms, leaving it unlocked and unattended each time. When questioned, RN #1 acknowledged the cart should be locked when not in use. The Director of Nursing (DON) confirmed that medication carts should be locked when unattended and subsequently locked cart #2.
Inaccurate Documentation of Medication Side Effects
Penalty
Summary
The facility failed to ensure accurate documentation of medication side effects for a resident who was being monitored for unnecessary medications. The resident had diagnoses including anxiety, depression, and atrial fibrillation, and was prescribed antianxiety, anticoagulant, and antidepressant medications. Physician's orders required staff to monitor and document any side effects in the progress notes if they occurred. However, the October, November, and December 2024 Treatment Administration Records (TARs) indicated multiple instances of side effects for each medication, but the progress notes did not reflect any documentation of these side effects. Interviews with the LPN and the Director of Nursing (DON) revealed that the charge nurses were responsible for monitoring and documenting medication side effects. The LPN stated that they had documented 'yes' on the TARs to indicate monitoring for side effects, not that the resident had actually experienced them. The DON confirmed that the TARs were reviewed by multiple staff members, including the Assistant Director of Nursing (ADON), consultant nurse, and pharmacist, and acknowledged the need for education to ensure accurate documentation. This discrepancy between the TARs and progress notes led to the deficiency in maintaining accurate medical records for the resident.
Arbitration Agreement Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that arbitration agreements included necessary language informing residents and their representatives of their rights. Specifically, the agreements did not state that residents or their representatives could rescind the agreement within 30 days of signing. Additionally, the agreements lacked language clarifying that signing was not a condition for admission or continued care. This deficiency was identified in the cases of three residents, each with significant medical conditions such as congestive heart failure and unspecified dementia. The administrator, who was relatively new to the facility, was unaware of why the arbitration agreements were missing this critical information. Upon review, it was found that 56 residents had signed these agreements, indicating a widespread issue. The administrator acknowledged the lack of necessary language in the agreements but could not provide an explanation for the oversight.
Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for catheter tubing for two residents. Resident #2, diagnosed with obstructive bladder, was observed multiple times with their catheter tubing and drainage bag on the floor or touching the fall mat. These observations occurred while the resident was in bed and in a wheelchair, indicating a consistent failure to maintain the catheter tubing off the floor as per the facility's policy. Resident #27, who had a neurogenic bladder and a history of UTIs, was also observed with catheter tubing hanging below their wheelchair and touching the floor. Despite a physician's order to maintain and monitor the suprapubic catheter with a bedside drainage bag, the tubing was not kept off the floor. Staff, including CNA #1 and the DON, acknowledged that the catheter bag and tubing should not be on the floor, indicating a lapse in adherence to infection control protocols.
Failure to Inspect Hospice-Supplied Bed Leads to Resident Incident
Penalty
Summary
The facility failed to inspect a hospice-supplied bed for safety before it was used by a resident, leading to an incident involving a resident with a history of falling. The facility's policy, dated March 2023, required that bed frames, mattresses, and bed rails be checked for compatibility and size prior to use. However, the maintenance staff did not inspect hospice-supplied beds when they were brought into the facility. This oversight resulted in an incident where the headboard separated from the frame, causing the resident to slide from the bed and land on their knees with their head resting against the mattress and bed rail. The incident was documented in a progress note, and the resident's representative confirmed the headboard separation. The resident recalled the incident, stating they were too weak to get up but did not suffer any injury they could recall. However, the ADON noted a small skin tear on the resident's neck where it rested against the side rail. The maintenance staff admitted to performing bed inspections only quarterly or when something malfunctioned, and the ADON acknowledged that bed inspections should be done prior to use by a resident, as per policy.
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 105 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) |
|---|---|---|---|---|
| Grace Skilled Nursing And Therapy Jenks | 0.9 mi | ★★★★★ | 11 | 0 |
| Zarrow Pointe | 2 mi | ★★★★★ | 2 | 0 |
| Ambassador Manor Nursing Center | 2.6 mi | ★★★★★ | 4 | 0 |
| The Villages At Southern Hills | 2.8 mi | ★★★★★ | 0 | 0 |
| Montereau, Inc. | 3.2 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.