Above 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 Zarrow Pointe during CMS and state inspections, most recent first.
A required discharge assessment was not completed or transmitted for a resident who was discharged to home, despite documentation showing the resident was cognitively intact and discharge planning was in progress. The omission was confirmed by the MDS coordinator upon review of the clinical record.
A resident admitted to hospice care for late effects of a cerebrovascular accident did not have their significant change MDS assessment accurately coded to reflect a life expectancy of less than six months or their hospice status, despite a physician's order and confirmation by the MDS coordinator.
A resident with severe cognitive and physical impairments did not have a care plan specifying the required level of staff assistance for bed mobility and incontinent care, despite documentation and staff observations indicating frequent need for two-person assistance. This omission led to inconsistent care practices and resulted in the resident falling from bed and sustaining significant injuries when a single CNA attempted to reposition the resident without adequate help.
A resident with severe cognitive impairment and high fall risk, who was dependent on staff for bed mobility, fell from bed during incontinent care when only one staff member attempted to reposition them. Documentation and staff interviews revealed inconsistent understanding and implementation of the required two-person assistance, resulting in the resident sustaining a femur fracture and other injuries.
A resident with severe cognitive impairment and dementia experienced a fall resulting in injury. Although the physician was promptly notified and care was provided, the resident's family was not informed of the incident until several hours later, contrary to facility policy requiring immediate notification. Staff interviews confirmed the delay and inconsistent understanding of notification procedures.
The facility failed to maintain resident dignity by allowing a CNA to make a demeaning comment to a resident and by not ensuring that clothing labels were not visible on another resident's socks. Staff acknowledged the inappropriateness of the comment and the visibility of the labels.
The facility failed to revise care plans for two residents, leading to inaccuracies in their documented care needs. One resident's care plan did not reflect a recent amputation and wound care requirements, while another resident's care plan inaccurately documented hospice services despite discharge over a year ago.
The facility failed to secure harmful chemicals, which were found in an unlocked room connecting two dining rooms. Various cleaning chemicals were observed unsecured, and staff confirmed the room was not locked due to the absence of a key. The facility had six residents requiring wander guards and a total census of 58 residents.
A resident with hemiplegia and hemiparesis was found with significant bruising and swelling to the left labia majora and minora. Despite staff following protocol to notify the charge nurse and complete incident reports, the DON did not report the injury to the Oklahoma State Department of Health as required by state and federal regulations.
The facility failed to develop a discharge summary for a resident with pneumonia and bronchitis who was discharged to an assisted living facility with home health services. Despite policy requirements, no discharge summary was found in the resident's medical record, and the DON confirmed the absence of necessary documentation.
A facility failed to obtain a physician-ordered chem eight lab test for a resident with severe protein-calorie malnutrition, hypertension, and chronic obstructive pulmonary disease. The DON confirmed the lab order process, but the lab results were not found.
The facility failed to ensure food items were properly secured, dated, and labeled during a kitchen observation. Bread in the dining room refrigerator, a carton of au gratin potatoes in the dry storage area, and frozen bread bowls and tri-color pasta in the walk-in freezer were all found without proper labeling or expiration dates. The Food and Beverage Director confirmed these deficiencies.
Failure to Complete and Transmit Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a required discharge assessment for one resident who was discharged to home. Record review showed that a 5-day assessment indicated the resident had intact cognition and was actively being prepared for discharge. However, after the resident was discharged, there was no evidence in the electronic clinical record that a discharge assessment had been completed. During an interview, the MDS coordinator confirmed that the discharge assessment should have been completed but was not.
Inaccurate Coding of Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for one resident who was admitted to hospice care. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for hospice admission due to late effects of a cerebrovascular accident. However, the significant change MDS assessment did not reflect the resident's life expectancy of less than six months, as required, and was not coded to indicate the resident's hospice status at the time. The MDS coordinator confirmed that the assessment was related to the initiation of hospice services but acknowledged that the MDS was not accurately coded to reflect the resident's current condition.
Failure to Specify Assistance Needed for Bed Mobility and Incontinent Care in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that specified the amount of assistance required for incontinent care and bed mobility for a resident with severe cognitive impairment and significant physical limitations. Despite documentation and staff observations indicating that the resident frequently required two-person assistance for these activities, the care plan did not reflect this need. The care plan only addressed two-person assistance for transfers with a mechanical lift and fall risk interventions, omitting explicit instructions for bed mobility and incontinent care. Multiple assessments and documentation reports showed that the resident was dependent on staff for rolling and was incontinent of urine, with frequent instances where two staff members provided assistance for toileting and bed mobility. However, staff interviews revealed inconsistencies in the understanding and implementation of the required level of assistance, with some staff stating that one-person assistance was sometimes used, while others reported always using two-person assistance. The lack of clear, consistent care plan directives contributed to confusion among staff regarding the resident's needs. An incident occurred in which the resident fell out of bed during incontinent care, resulting in significant injuries, including a fracture and hematoma. The incident report and subsequent interviews indicated that the fall happened when a single CNA attempted to reposition the resident without adequate assistance, as the care plan did not specify the required two-person assistance for bed mobility and incontinent care. This deficiency in care planning and communication directly contributed to the resident's injury.
Failure to Provide Consistent Two-Person Assistance During Incontinent Care Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from accident hazards and received adequate supervision to prevent accidents during incontinent care. The resident, who was severely cognitively impaired, dependent on staff for bed mobility, and at high risk for falls, experienced a fall from bed during incontinent care. Documentation and assessments indicated that the resident often required two-person assistance for bed mobility and incontinent care, but there was inconsistency among staff regarding the level of assistance actually provided. Some staff reported providing care independently, while others used two-person assistance, and the care plan and documentation were not consistently aligned. On the day of the incident, a CNA attempted to reposition the resident by pulling a draw sheet while standing on the side of the bed against the wall. The resident rolled out of bed and sustained significant injuries, including a fracture of the left distal femur and a hematoma with a skin tear on the right hand. The resident was transferred to the hospital for evaluation and returned to the facility with an immobilizer and additional care needs. The incident occurred despite the presence of fall prevention measures such as a low bed, fall mat, and non-skid socks. Interviews with staff and review of documentation revealed confusion and inconsistency regarding the required level of assistance for the resident. While some staff believed the resident only needed one-person assistance, others documented and practiced two-person assistance. The facility's documentation showed that two-person assistance was provided in a significant number of care opportunities, but this was not consistently communicated or implemented among all staff, leading to the fall and resulting injury.
Failure to Immediately Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's responsible party following an accident/fall, as required by facility policy. According to the record review, a resident with severe cognitive impairment and a diagnosis of dementia experienced a fall at 4:35 a.m., resulting in a significant hematoma and pain. The incident note documented that the physician was notified and x-rays were ordered, and it was indicated that the resident's power of attorney (POA) had been notified. However, interviews revealed that the family was not informed of the fall until several hours later, between 7:00 a.m. and 8:00 a.m. Staff interviews confirmed that the nurse on duty did not notify the resident's family immediately after the fall, instead waiting until later in the morning. The RN stated there was no specific time frame for notification other than before the end of the shift, while the DON clarified that immediate notification was required. The RN care coordinator also acknowledged that the responsible party should have been notified after the resident was assessed and the physician was contacted, but could not explain the delay. The facility's policy, dated May 2017, explicitly required immediate notification of the resident's representative following any accident or incident resulting in injury.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence and self-determination. Specifically, a CNA was observed asking a resident with Parkinson's and Dementia if they wanted to be fed like a baby, which was disrespectful and demeaning. The resident had previously expressed that they did not want to be treated like a baby. The DON and other staff members acknowledged that such comments were inappropriate, regardless of the relationship between the resident and the staff member. Additionally, the facility failed to ensure that resident clothing labels were not visible, compromising the dignity of a resident with Alzheimer's disease and anxiety disorder. The resident was observed multiple times with their name labels clearly visible on their socks. Staff members, including CNAs and laundry personnel, confirmed that labels were placed on the outside of socks to avoid discomfort, but this practice resulted in visible labels, which is against the facility's dignity policy.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise care plans for two residents, leading to inaccuracies in their documented care needs. Resident #37, who had undergone a left above knee amputation, was readmitted to skilled care with a wound vac in place. However, the care plan was not updated to reflect the new wound care requirements, instead still documenting a venous ulcer of the left lower calf. Despite the facility's ongoing Performance Improvement Project for care plans, the necessary updates were not made in a timely manner. Resident #22, diagnosed with corticobasal degeneration and hypertension, had a care plan that inaccurately documented hospice services. The resident's care plan, last reviewed on 01/30/24, indicated a terminal prognosis and hospice care, although the resident had been discharged from hospice over a year ago. The MDS Coordinator acknowledged the oversight, stating that the care plan had not been updated to reflect the resident's current status. This lapse occurred despite daily efforts to update care plans based on new orders and morning meetings to review necessary updates.
Failure to Secure Harmful Chemicals
Penalty
Summary
The facility failed to ensure harmful chemicals were secured, posing a potential hazard to residents. During an observation, various cleaning chemicals, including dish detergent, lime and calcium remover, cleaner with bleach, and stainless steel cleaner, were found unsecured on top of the dishwasher and on a rack attached to the sink in a room connecting two dining rooms. Both doors to this room were observed to be open. Interviews with staff revealed that the room was not locked because there was no key, and staff were in and out of the room throughout the day. The Dietary Manager confirmed that the door was only closed from around 7:00 p.m. to 7:00 a.m. The facility had six residents requiring wander guards for safety and a total census of 58 residents at the time of the observation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the Oklahoma State Department of Health (OSDH). The resident, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction and dysphagia, was found with significant bruising and swelling to the left labia majora and minora. The incident was documented by an LPN, and the physician, DON, Care Coordinator, and POA were notified. However, there was no State Reportable incident located for this injury, and the DON confirmed that the incident was not reported to OSDH as required by state and federal regulations. Interviews with staff, including CNAs and LPNs, indicated that they followed the protocol of notifying the charge nurse and completing incident reports when bruising of unknown origin was observed. Despite this, the DON, who was responsible for completing State Reportable incidents, did not report the injury to OSDH. The DON reviewed the State Reportable incidents and confirmed that no report was made for the incident involving the resident. The facility's failure to report the injury of unknown origin constitutes a deficiency in adhering to abuse prevention policies and state reporting requirements.
Failure to Develop Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was developed for one resident reviewed for discharge. The resident had diagnoses including pneumonia and bronchitis and was scheduled to be discharged to an assisted living facility with home health services. Despite the facility's policy requiring a discharge summary and post-discharge plan, no discharge summary was found in the resident's medical record. The Director of Nursing (DON) confirmed that the discharge summary should have included the resident's condition, rehabilitation potential, medications, orders, follow-up directions, and reason for leaving, but acknowledged that no such documentation could be located.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for a resident diagnosed with severe protein-calorie malnutrition, hypertension, and chronic obstructive pulmonary disease. A physician had ordered a chem eight lab test for delirium to be conducted one time only. However, there was no documentation in the resident's clinical record indicating that this lab test was obtained. The Director of Nursing (DON) confirmed that the process for ordering labs involved placing the order in the requisition book and the lab book for the lab staff to draw the sample. Despite this process, the lab results for the chem eight test were not found.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to ensure food items were properly secured, dated, and labeled during a kitchen observation. The Food Receiving and Storage policy, dated 07/14, required all foods stored in the refrigerator or freezer to be covered, labeled, and dated. On 04/01/24 at 9:55 a.m., bread in the dining room refrigerator was observed without a label, and a dietary aide stated it was for the birds. At 10:03 a.m., a carton of au gratin potatoes was found open and unlabeled in the dry storage area, which the Food and Beverage Director confirmed. At 10:07 a.m., frozen bread bowls and tri-color pasta in the walk-in freezer were also found without expiration dates or labels, as confirmed by the Food and Beverage Director. The facility had a census of 58 residents at the time of the observation.
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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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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) |
|---|---|---|---|---|
| Ambassador Manor Nursing Center | 1.2 mi | ★★★★★ | 4 | 0 |
| The Villages At Southern Hills | 1.7 mi | ★★★★★ | 0 | 0 |
| University Village Retirement Community | 2 mi | ★★★★★ | 0 | 0 |
| Colonial Manor Nursing Home | 2.1 mi | ★★★★★ | 2 | 0 |
| Grace Skilled Nursing And Therapy Jenks | 2.4 mi | ★★★★★ | 11 | 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 July 2026) and official state health department websites.