Deficiencies (last 6 years)
Deficiencies (over 6 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
81% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Renewal
Census: 38
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
A relicensure survey was conducted from 04/16/25 through 04/17/25 in conjunction with a complaint investigation (#OK00073375) regarding failure to protect residents from access to non-prescribed potentially dangerous drugs.
Complaint Details
The complaint investigation was related to an allegation that the facility failed to protect residents from access to non-prescribed potentially dangerous drugs. The investigation included observations, interviews, and record reviews. No deficiencies were cited.
Findings
No deficiencies were cited during the relicensure survey and complaint investigation. The facility was toured, residents and staff were observed and interviewed, and relevant records were reviewed with no issues found.
Report Facts
Facility Census: 38
Complaint Participants Sample: 3
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of bed rails in the facility, specifically to verify informed consent and proper documentation for residents using bed rails.
Findings
The facility failed to obtain informed consent prior to the use of bed rails for two sampled residents. There was no documentation of bed rail utilization in the care plans, and the facility lacked a specific policy on bed rails.
Deficiencies (1)
F 0700: The facility failed to ensure informed consent was obtained prior to the use of bed rails for two residents. Documentation of bed rail use was also missing from the care plans.
Report Facts
Residents with bed rails: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated informed consents had not been documented for residents prior to bed rail use | |
| Administrator | Stated informed consent had not been obtained prior to bed rail implementation and facility had no specific policy |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Sep 25, 2024
Visit Reason
A complaint investigation was conducted due to allegations that the facility failed to ensure residents were free from physical, verbal, or psychosocial abuse.
Complaint Details
The complaint investigation was substantiated with findings of abuse by CNA #1 against Resident #1 and Resident #2. The CNA was suspended immediately and terminated. The facility notified local police and Adult Protective Services (APS).
Findings
The investigation found that two of three sampled residents were subjected to abuse by a certified nurses aide (CNA #1), who slapped one resident multiple times and grabbed another resident's forearm causing pain. The CNA was suspended and terminated. The facility was found to have deficiencies related to resident abuse.
Deficiencies (1)
Failed to ensure residents were free from mental and physical abuse for two of three sampled residents.
Report Facts
Facility Census: 42
Sampled residents for abuse investigation: 3
Residents affected by abuse: 2
Dates of investigation: 2024-09-24 to 2024-09-25
Date of abuse incident: Sep 10, 2024
Date of CNA termination: Sep 13, 2024
Date of plan of correction completion: Oct 16, 2024
Date of off-site revisit: Oct 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tempal Killman | Enforcement Analyst | Signed enforcement and correspondence letters related to the complaint investigation and plan of correction |
| Jacob Will | Administrator | Facility administrator named in correspondence and plan of correction |
Inspection Report
Renewal
Census: 44
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
A re-licensure survey was conducted from February 12, 2024 through February 15, 2024 to assess compliance for license renewal of the assisted living center.
Findings
No deficiencies were cited during the licensure inspection conducted at the facility.
Report Facts
Census: 44
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
The inspection was conducted following a complaint regarding a violation of a resident's right to privacy during care.
Complaint Details
The complaint was substantiated. A CNA posted an unauthorized video of a resident without consent, violating privacy rights. The CNA was terminated.
Findings
The facility failed to ensure a resident's privacy when a CNA recorded and posted a video of a resident being transferred without consent. The allegation was substantiated and the CNA was terminated.
Deficiencies (1)
F 0583: The facility failed to keep residents' personal and medical records private and confidential. A CNA recorded and posted a video of a resident being transferred without consent, violating the resident's privacy rights.
Report Facts
Residents present: 42
Residents reviewed for privacy: 3
Residents affected: 1
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
Annual inspection survey of Covenant Living at Inverness nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 16, 2021
Visit Reason
The inspection was conducted to investigate complaints related to Medicare Part A billing, care plan deficiencies regarding medication management, infection control practices, and care plan revisions for residents receiving antibiotics and contact isolation precautions.
Complaint Details
The investigation was complaint-driven, focusing on Medicare Part A billing issues, medication care plan deficiencies, and infection control practices. The substantiation status is not explicitly stated.
Findings
The facility failed to ensure proper Medicare Part A consolidated billing for outpatient hospital services, did not develop comprehensive person-centered care plans for residents on insulin and psychotropic medications, failed to revise care plans to include antibiotic therapy and contact isolation precautions, and did not maintain adequate infection prevention and control practices including proper PPE use and hand hygiene.
Deficiencies (4)
F 0620: The facility failed to ensure a claim for outpatient hospital services was submitted and paid as Medicare Part A consolidated billing for one resident during a Medicare Part A stay.
F 0656: The facility failed to develop comprehensive person-centered care plans related to insulin and psychotropic medications for two residents, with care plans containing inaccurate or missing medication information.
F 0657: The facility failed to revise the care plan to include antibiotic therapy and contact isolation precautions for one resident receiving antibiotics and on contact isolation.
F 0880: The facility failed to maintain an infection prevention and control program, including failure of staff to don appropriate PPE and perform hand hygiene when exiting rooms of residents on contact precautions.
Report Facts
Residents on psychotropic medications: 17
Residents on antibiotics: 5
Residents on contact isolation precautions: 3
Residents on Medicare Part A services: 5
Residents on contact precautions/quarantined due to new admission and not vaccinated for COVID-19: 3
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 5
Date: May 6, 2021
Visit Reason
The visit was conducted as a Covid-19 focused infection control survey along with a complaint investigation regarding allegations of failure to protect residents from sexual exploitation and failure to administer medications as ordered.
Complaint Details
Complaint investigation was initiated based on allegations that the center failed to protect residents from sexual exploitation and failed to administer medications as ordered. Deficient practices were substantiated related to these allegations. The facility was required to submit plans of correction and a follow-up investigation was planned.
Findings
The facility was found deficient in ensuring medication was administered as ordered for one resident, protecting a cognitively impaired resident from sexual abuse, thoroughly investigating allegations of abuse, and maintaining proper medication records and destruction logs. The deficiencies represented potential for more than minimal harm but no actual harm was identified.
Deficiencies (5)
Failure to ensure medication was administered as ordered for one resident.
Failure to protect a cognitively impaired resident from sexual abuse and failure to thoroughly investigate abuse allegations for two residents.
Failure to submit required incident reports to the Oklahoma State Department of Health for two residents.
Failure to implement policy for medication destruction and maintain proper medication destruction logs for discontinued medications.
Failure to maintain physician's orders in clinical records and maintain records of discontinued medications for three residents.
Report Facts
Total residents: 35
Investigation dates: 2021-05-04 to 2021-05-06
Plan of correction completion date: Jun 25, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billie Seeman | RN Clinical Health Facility Surveyor | Named as surveyor who completed the report. |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed enforcement letters related to the survey. |
| Rickey Lee | Administrator | Facility administrator named in the report and correspondence. |
Inspection Report
Renewal
Capacity: 91
Deficiencies: 0
Date: Mar 30, 2021
Visit Reason
This document is a license renewal issued to Tulsa Hills Community, Inc. for the operation of a Continuum of Care Facility.
Findings
The document certifies that the facility is licensed to conduct and maintain a Continuum of Care Facility under a renewal license type effective from 04/30/2021 to 04/29/2022.
Report Facts
Maximum licensed beds: 91
Inspection Report
Renewal
Capacity: 91
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
This document serves as a license renewal for the Continuum of Care Facility known as Covenant Living at Inverness, certifying the facility's authorization to operate for the period from 04/30/2020 to 04/29/2021.
Findings
The document certifies that Tulsa Hills Community, Inc. is licensed to conduct and maintain a Continuum of Care Facility with a maximum capacity of 91 beds. No deficiencies or findings are noted in this license renewal document.
Report Facts
Licensed capacity: 91
Inspection Report
Original Licensing
Capacity: 91
Deficiencies: 0
Date: Oct 31, 2019
Visit Reason
The purpose of this document is to transmit a continuum of care facility initial license to Tulsa Hills Community, Inc., d/b/a Covenant Living of Tulsa Hills, effective November 1, 2019.
Findings
The initial license was issued on October 31, 2019, reflecting that the facility is licensed for ninety-one beds, including nursing and assisted living beds.
Report Facts
Licensed beds: 91
Nursing beds: 44
Assisted living beds: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Espanola Bowen | Administrative Program Manager | Signed letter transmitting initial license |
| Michael Todd | Health Planning Specialist | Contact for licensing questions |
Notice
Capacity: 91
Deficiencies: 0
Date: Oct 30, 2019
Visit Reason
The document serves as an approval order and Certificate of Need for the purchase of Inverness Village, a 91-bed licensed Continuum of Care Facility, by Tulsa Hills Community, Inc.
Findings
The Oklahoma State Department of Health reviewed the application, financial resources, staffing, and compliance history, and found no evidence of substandard care or disqualifying factors, approving the Certificate of Need for the acquisition.
Report Facts
Licensed beds: 91
Capital cost: 41000000
Loan amount: 44000000
Financial reserves: 427392.42
Line of credit: 6000000
Experience: 60
Penalty threshold: 35000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bailey | Chief Operating Officer | Signed the Certificate of Need order |
| Mark Easlburg | Person with authority in Tulsa Hills Community, Inc. | |
| Matthew Marlowe | Person with authority in Tulsa Hills Community, Inc. | |
| Sarah Bentley | Person with authority in Tulsa Hills Community, Inc. | |
| Terri Cunliffe | Person with authority in Tulsa Hills Community, Inc. | |
| Jodi Holt | CFO | Person with authority in Tulsa Hills Community, Inc. |
| David Erickson | Person with authority in Tulsa Hills Community, Inc. | |
| Españiola Bowen | Administrative Program Manager | Signed the cover letter for the Certificate of Need |
Inspection Report
Renewal
Census: 44
Deficiencies: 0
Date: May 29, 2019
Visit Reason
A re-licensure survey was conducted on May 28 and May 29, 2019, to assess compliance for license renewal at the assisted living center.
Findings
No deficiencies were cited during the inspection, indicating compliance with applicable regulations.
Report Facts
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed the cover letter reporting no deficiencies |
Inspection Report
Renewal
Capacity: 91
Deficiencies: 0
Date: 03 30 2022 LICENSE 110763
Visit Reason
This document serves as a license renewal for the Continuum of Care Facility named Covenant Living at Inverness, certifying the facility to conduct and maintain operations.
Findings
The document certifies that Tulsa Hills Community, Inc. is licensed to operate a Continuum of Care Facility with a maximum capacity of 91 beds. It does not include inspection findings or deficiencies.
Report Facts
Maximum licensed beds: 91
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