Inspection Reports for Chapters Living of Tulsa
7807 S MINGO RD, TULSA, OK, 74133
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 6, 2025, found deficiencies related to meal completeness, failure to report allegations of abuse, and notification to the nurse aide registry. Earlier inspections showed a pattern of deficiencies involving medication administration, reporting and communication issues, and some concerns with staffing and food service. Complaint investigations included substantiated cases of medication errors and abuse reporting failures, while many other complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges with regulatory compliance, with deficiencies continuing into the most recent inspection.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
27 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: Mar 6, 2025
Visit Reason
A licensure inspection with multiple complaint investigations was conducted at Chapters Living of Tulsa to investigate allegations including abuse, failure to report abuse, failure to secure exit doors, failure to notify legal surrogates of medical changes, and failure to provide family/legal surrogate access to medical records.
Complaint Details
Multiple complaints investigated including failure to prevent abuse or involuntary seclusion, failure to report abuse within required timeframes, failure to secure exit doors to prevent elopement, failure to notify legal surrogates of medical regimen changes, and failure to provide family/legal surrogate access to medical records. The investigations included interviews, observations, and record reviews. One specific abuse allegation involved a nurse aide allegedly hitting a resident with a water bottle, which was not reported to the state as required.
Findings
The facility was found deficient in ensuring residents received complete meals as approved by a registered dietitian, failed to report allegations of abuse to the Oklahoma State Department of Health and the Nurse Aide Registry as required, and had other cited deficiencies. The facility was given an opportunity to correct these deficiencies and submitted an acceptable plan of correction.
Deficiencies (3)
Facility failed to ensure residents received a complete lunch meal approved by the registered dietitian for 6 of 8 sampled residents.
Facility failed to report allegations of abuse as required for 1 sampled resident.
Facility failed to notify the nurse aide registry of an allegation of abuse involving a nurse aide for 1 sampled resident.
Report Facts
Facility census: 27
Sampled residents: 8
Residents affected by meal deficiency: 6
Complaint investigations: 5
Date of inspection: Mar 6, 2025
Date of report completion: Mar 17, 2025
Date of plan of correction acceptance: Mar 27, 2025
Date of substantial compliance: May 2, 2025
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
A complaint investigation was conducted at Known Memory Care due to allegations of inadequate medical care and services, medication administration issues, abuse, neglect, inadequate staffing, and food safety concerns.
Complaint Details
The complaint investigation was initiated due to allegations that the center failed to provide adequate medical care and services, failed to administer medications according to physician orders, failed to ensure adequate hydration, failed to provide activities according to plan of care, failed to notify residents/representatives of changes, failed to treat residents with dignity and respect, failed to provide adequate lighting and staffing, failed to ensure food safety and proper dietary staffing, and failed to prevent abuse and neglect.
Findings
The investigation found multiple deficiencies including failure to maintain resident records, inadequate medical care, medication errors, abuse and neglect concerns, insufficient staffing, and food safety violations. The facility was given an opportunity to correct these deficiencies and submitted an acceptable plan of correction.
Deficiencies (1)
Failed to ensure resident records were maintained and available for five years after transfer, discharge, or death.
Report Facts
Investigation Dates: 2023-10-10 to 2023-10-11
Deficiency correction date: Nov 7, 2023
Plan of Correction submission date: Oct 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Ray | Administrator | Named in relation to plan of correction and facility administration |
| Lisa Calvin | Enforcement Analyst | Signed enforcement correspondence |
| Tempal Killman | Administrative Assistant II | Signed acceptance letter for plan of correction |
Inspection Report
Renewal
Census: 30
Deficiencies: 3
Date: Jun 21, 2023
Visit Reason
A relicensure survey was conducted at the assisted living facility to assess compliance with state licensure requirements.
Findings
The facility was found deficient in maintaining dish machine sanitation, ensuring direct care staff received CPR and first aid training, and safe medication administration practices including crushing medications that should not be crushed and failure to monitor blood pressure prior to medication administration.
Deficiencies (3)
Failed to maintain the dish machine sanitation according to manufacturer's minimum requirements.
Failed to ensure direct care staff received CPR and first aid training for one of five sampled staff.
Failed to administer medications per physician's orders and standards of practice for two of seven sampled residents, including crushing medications that should not be crushed and not monitoring blood pressure prior to administration.
Report Facts
Residents present: 30
Medication error rate: 10
Sanitizing agent level: 50
Sanitizing agent level range: 110-125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Ray | Administrator | Signed the plan of correction documents. |
| Lisa Calvin | Enforcement Analyst | Signed enforcement correspondence. |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 2
Date: Mar 14, 2023
Visit Reason
A complaint investigation was conducted due to allegations that the facility failed to ensure heat was available in all resident rooms and electrical outlets were working, failed to communicate facility to facility for resident care, and failed to report a fire, heat, and electrical outages to the State Agency.
Complaint Details
Complaint #OK00060222 involved allegations of failure to ensure heat and electrical outlets in resident rooms, failure to communicate facility to facility, and failure to report a fire and electrical outages. The first and third allegations were substantiated; the second was unsubstantiated.
Findings
The investigation substantiated deficient practices related to inadequate heat and electrical outlets in resident rooms and failure to report a fire and related incidents to the State Agency. The facility was clean and residents were observed to be well cared for. The allegation regarding failure to communicate facility to facility was unsubstantiated.
Deficiencies (2)
Facility failed to ensure heat was available in all resident rooms and electrical outlets were working.
Facility failed to report a fire, heat and electrical outages to the State Agency.
Report Facts
Residents living in facility: 26
Incident report delay: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anita Newman | LPN, CHFS | Completed the investigative report dated 2023-03-15. |
| Lisa Calvin | Enforcement Analyst | Signed enforcement and notice letters related to the investigation. |
Inspection Report
Renewal
Capacity: 46
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
This document serves as a license renewal certificate for 7807 S Mingo Rd Operations, LLC to conduct and maintain an Assisted Living Center known as Known Memory Care.
Findings
The license is issued pursuant to Oklahoma statutes and state board of health regulations, authorizing operation of the facility with a maximum capacity of 46 beds. The license is effective from 2023-01-03 through 2025-02-14.
Report Facts
Maximum licensed beds: 46
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on an allegation that the facility failed to ensure residents were not neglected.
Complaint Details
The allegation that the facility failed to ensure residents were not neglected was unsubstantiated (US). No deficiencies were cited related to this complaint.
Findings
The investigation found the allegation to be unsubstantiated. The facility was clean and orderly, residents were well cared for, and staff were observed assisting residents appropriately. Staffing levels were at or above guidelines, and no neglect was found.
Report Facts
Sample residents investigated: 3
Investigation dates: Investigation conducted on 2022-09-28 and 2022-11-03
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Analyst | Author of the complaint investigation report |
| Leasa Welch | RN | Completed the determination summary and follow-up action |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Jul 13, 2022
Visit Reason
A complaint survey was conducted due to allegations regarding neglect, medication administration, misappropriation of property, timely incontinent care, and staffing adequacy.
Complaint Details
The complaint included five allegations: 1) failure to ensure residents were not neglected (unsubstantiated), 2) failure to ensure residents were administered medications as ordered and medications were available (substantiated), 3) failure to ensure resident’s property was not misappropriated (unsubstantiated), 4) failure to provide timely incontinent care (unsubstantiated), and 5) failure to provide adequate staff for dependent residents (unsubstantiated).
Findings
The investigation substantiated deficient practice related to medication administration for three residents, including failure to maintain accurate medication records and failure to administer medications as ordered. Other allegations including neglect, misappropriation of property, timely incontinent care, and staffing adequacy were unsubstantiated.
Deficiencies (1)
Facility failed to maintain an accurate written record of medication administration for three residents and failed to administer medications as ordered for one resident.
Report Facts
Residents: 35
Missed medication doses: 15
Plan of Correction Completion Date: Sep 30, 2022
Date of Correction: Oct 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| B. Garrison | R.N. | Signed the investigative report completed on 07/14/2022. |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed enforcement correspondence and investigative letters. |
| Tempal Killman | Administrative Assistant II | Signed acceptance letter of amended plan of correction. |
Inspection Report
Renewal
Capacity: 46
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
This document serves as a license renewal for the Assisted Living Center Colonial Oaks at Tulsa, certifying the facility to conduct and maintain an assisted living center.
Findings
The license renewal confirms the facility meets the requirements set by the Oklahoma State Department of Health and is authorized to operate with a maximum capacity of 46 beds.
Report Facts
Maximum licensed beds: 46
Inspection Report
Renewal
Capacity: 46
Deficiencies: 0
Date: Jun 2, 2021
Visit Reason
This document serves as a license renewal for the Assisted Living Center known as Colonial Oaks at Tulsa, authorizing the facility to conduct and maintain operations.
Findings
The license renewal certifies that the facility meets the requirements set forth by the Oklahoma State Department of Health and is authorized to operate with a maximum capacity of 46 beds.
Report Facts
Maximum licensed beds: 46
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The inspection was conducted as a complaint investigation in conjunction with a COVID-19 Special Focus Infection Control Survey to determine if the facility was in compliance with infection prevention and control practices related to COVID-19.
Complaint Details
The complaint alleged that the center failed to provide a safe environment. The investigation found the allegation unsubstantiated (US). No deficient practices were identified related to this allegation.
Findings
No deficiencies were cited during the investigation. The allegation that the center failed to provide a safe environment was unsubstantiated after observations, interviews, and record reviews.
Report Facts
Total residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tim Nicholson | LPN | Signed the report as the person completing the investigation |
Inspection Report
Routine
Census: 26
Deficiencies: 0
Date: Jan 22, 2021
Visit Reason
The Oklahoma State Department of Health conducted a COVID-19 Special Focus Infection Control Survey to determine if the facility was in compliance with proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited during the COVID-19 Special Focus Survey conducted on January 22, 2021.
Report Facts
Total residents: 26
Inspection Report
Abbreviated Survey
Census: 36
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
The visit was a COVID-19 Special Focus Infection Control Survey conducted to determine if the facility was in compliance with proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited during the COVID-19 Special Focus Survey conducted on December 7, 2020.
Report Facts
Total residents: 36
Inspection Report
Original Licensing
Capacity: 46
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
This document transmits the corrected initial license for 7807 S Mingo Rd Operations, LLC d/b/a Autumn Leaves of Tulsa, an assisted living center, effective August 18, 2020, correcting the previously issued license date.
Findings
The license was issued pursuant to Oklahoma statutes and regulations, authorizing the facility to operate as an assisted living center with a maximum capacity of 46 beds.
Report Facts
Maximum licensed beds: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Karuga | Health Planning Specialist | Reviewed the contract material for the license application |
| Espaniola Bowen | Administrative Program Manager | Signed the licensing letter as licensure official |
| Lisa McAlester | RN, AL/RC/ADC Program Manager/Coordinator | Copied on the licensing letter |
| Russell Ramzel | Copied on the licensing letter via email |
Notice
Capacity: 46
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
This document is a license issued to Autumn Leaves of Tulsa for operating an assisted living center, certifying compliance with state regulations.
Findings
The license certifies that Autumn Leaves of Tulsa is authorized to operate with a maximum capacity of 46 beds, effective from 08/18/2020 to 09/10/2020.
Report Facts
Maximum capacity: 46
Inspection Report
Routine
Census: 29
Deficiencies: 0
Date: Jun 10, 2020
Visit Reason
The visit was a COVID-19 Special Focus Infection Control Survey conducted to determine if the facility was in compliance with proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited during the COVID-19 Special Focus Survey conducted on June 10, 2020.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Feb 4, 2020
Visit Reason
A complaint investigation was conducted at Autumn Leaves of Tulsa on February 3-4, 2020, based on allegations related to contract refunds, abuse policy, medication administration, and provision of contracted services.
Complaint Details
Complaint investigation involved allegations that the center failed to ensure a refund was issued as contracted (unsubstantiated), failed to have and/or implement their abuse policy (unsubstantiated), failed to administer medications according to physician's orders (substantiated), and failed to ensure residents' contracted services were provided (unsubstantiated).
Findings
The investigation found one allegation substantiated related to medication administration, while other allegations including contract refunds, abuse policy, and contracted services were unsubstantiated. Deficiencies were cited related to medication administration.
Deficiencies (1)
An accurate written record of medications administered shall be maintained, including identity and signature of the person administering, medication administered within one hour of scheduled time, and documentation of medication condition and administration method. Medication error incident reports must be maintained.
Report Facts
Census: 33
Sample size: 7
Survey dates: 2020-02-03 to 2020-02-04
Plan of Correction due date: Feb 21, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justina Leach | RN/CHFS | Signed the complaint investigation report and determination summary. |
| Danna Wise | Administrator | Named as facility administrator and signed plan of correction acceptance letter. |
| Sue Davis | Long Term Care Enforcement Coordinator | Signed acceptance letter of plan of correction. |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed letter confirming correction of deficiencies after desk audit. |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 2
Date: Dec 20, 2019
Visit Reason
A re-licensure survey was conducted from 12/18/19 through 12/20/19 in conjunction with complaint #OK54430. The visit was a complaint investigation related to the center's failure to refund money as stated in the resident's contract.
Complaint Details
The complaint allegation that the center failed to refund money as stated in the resident's contract was substantiated.
Findings
Deficient practice was substantiated related to the allegation that the center failed to refund money as stated in the resident's contract. Additional violations unrelated to the complaint were also cited during the investigation.
Deficiencies (2)
The center failed to ensure a refund was issued for 1 of 1 sampled residents as contracted, with potential for more than minimal harm to all 23 residents.
Medication administration deficiencies were found, including failure to administer correct medication doses and lack of physician orders for topical medications.
Report Facts
Census: 23
Sampled residents: 11
Survey dates: 2019-12-18 to 2019-12-20
Plan of correction completion date: Jan 17, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danna Wise | Administrator | Named in relation to the refund money deficiency and plan of correction |
| Sue Davis | Enforcement Coordinator | Signed enforcement letters related to the complaint investigation |
| Justina Leach | RN/CHFS | Signed the investigative report |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 0
Date: Jun 17, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to an allegation that the center failed to ensure food was prepared and served in a sanitary manner.
Complaint Details
The allegation that the center failed to ensure food was prepared and served in a sanitary manner was unsubstantiated (US). No deficient practice was found related to this complaint.
Findings
The complaint was unsubstantiated with no deficiencies cited. The kitchen and food storage were found to be clean and compliant with regulations, and no complaints were received from staff, residents, or family members.
Report Facts
Census: 24
Investigation Dates: Investigation conducted on 2019-06-14 and 2019-06-17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed the cover letter of the complaint investigation report |
| Justina Leach | RN/CHFS | Signed the determination summary and follow-up action section of the investigative report |
Notice
Capacity: 46
Deficiencies: 0
Date: Apr 22, 2019
Visit Reason
This document serves as a license renewal certifying that Tulsa Memory Care, LLC is licensed to conduct and maintain an Assisted Living Center at the specified location.
Findings
The document certifies the renewal of the facility's license with a maximum capacity of 46 beds, effective from 02/16/2019 to 02/15/2020.
Report Facts
Maximum licensed beds: 46
Notice
Capacity: 46
Deficiencies: 0
Date: 02 07 2025 LICENSE 112605
Visit Reason
This document serves as a license renewal for Chapters Tulsa Opco, LLC, dba Chapters Living of Tulsa, to conduct and maintain an Assisted Living Center at 7807 S. Mingo Rd., Tulsa, OK.
Findings
The document certifies the facility's licensure status and authorizes operation with a maximum capacity of 46 beds. No inspection findings or deficiencies are reported.
Report Facts
Maximum licensed capacity: 46
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