Tulsa Center for Rehabilitation and Healthcare

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dignity was maintained while residents were assisted with meals for 1 (#2) of 3 sampled residents reviewed for dignity. The administrator identified eight residents who were dependent on staff for eating.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain infection control for residents with indwelling urinary catheters for 1 (#5) of 3 sampled residents reviewed for infection control. The administrator identified 11 residents with indwelling urinary catheters.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the call light system was functioning for 3 (#4, 6, and #8) of 5 sampled residents reviewed for functioning call lights. The administrator identified 121 residents resided at the facility. On [DATE] at 5:24 a.m., the call lights in room [ROOM NUMBER] and room [ROOM NUMBER] were observed to be on in the hallway. The call light alert box at the nurses' station was observed to show cord out for room [ROOM NUMBER] and room [ROOM NUMBER]. On [DATE] at 10:50 a.m., the call light box for room [ROOM NUMBER] was observed to be missing. Bare wires were observed to hang from the wall where it had been located. A policy titled Call Lights: Accessibility and Timely Response, dated 2025, read in part, Assure the facility is adequately equipped with a call light at each residents' bedside. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from abuse for 1 (#5) of 3 sampled residents reviewed for abuse. The administrator identified 125 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure daily weights were obtained according to physician orders for 1 (#1) of 3 sampled residents reviewed for daily weights. The administrator identified 114 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident diagnosed with diabetes mellitus, who was ordered a routine blood test to monitor blood sugar levels, received the test for 1 (#2) of 5 sampled residents reviewed for unnecessary medications. The DON stated 60 residents at the facility had diabetes and all had their A1C tested at least annually.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications were secure for 1 of 3 carts on the Southeast Hall. The DON identified 108 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff were compliant with Infection prevention protocols during the provision of tracheostomy care for 1 (#5) of 5 residents reviewed for infection control procedures. The administrator identified 3 residents with a tracheostomy resided in the facility. On 08/20/25 at 12:48 p.m., LPN #1 was observed to provide tracheostomy care for Res #5. After starting care, LPN #1 discovered supplies needed were not available in the room, LPN #1 removed their gloves and gown and left the room. On 08/20/25 at 1:15 p.m., LPN #1 returned to the room with supplies and donned a gown and gloves in the room. LPN #1was not observed to sanitize their hands. LPN #1 then opened a pair of sterile gloves, removed the gloves they had on and donned sterile gloves. LPN #1 was not observed to sanitize their hands between glove changes. [...]

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the OSDH within two hours for one (#4) of four sampled residents reviewed for abuse. The administrator reported the census was 104.

Inspectors wroteBased on record review and interview, the facility failed to use a gait belt for one (#3) of three residents who were sampled for assist with transfers. The administrator identified 106 resident resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure an assessment was transmitted timely for one (#87) of two sampled assessments reviewed for accuracy. The Administrator identified 109 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered for one resident (#58) of six sampled resident reviewed for medications. The Administrator stated 109 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure sufficient dietary staff to provide alternative meals. The Administrator identified 109 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure alternative meals were provided for three (#47, 48, and #73) of three sampled residents reviewed for meal service. The Administrator identified 109 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation and interview, the facility failed to ensure a shower stall and curtain was clean for one of one shower rooms observed. The Administrator identified 109 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide written information concerning the right to formulate an advance directive for two (#25 and #69) of three sampled residents who were reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 09/06/23, documented 99 residents resided at the facility.

Inspectors wroteBased on interview and record review, it was determined the facility failed to provide complete and informed advance notice of discharge from Medicare skilled services for three (#2, 16, and #146) of three residents who were reviewed for beneficiary protection notification. The Resident Census and Conditions of Residents report, documented 9 residents who had been discharged from Medicare skilled services in the last six months.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff sanitized their hands between glove changes during wound care for two (#7 and #62) of two residents observed for wound care, and between residents when administering medications. The Resident Census and Conditions of Residents report, dated 09/06/23, documented four residents with pressure ulcers, and 99 residents who resided at the facility who received medications.