Inspection Reports for
Saint Simeons Episcopal Home
3701 NORTH CINCINNATI, TULSA, OK, 74106
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
89% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 3
Date: Mar 4, 2025
Visit Reason
The inspection was conducted following allegations of abuse and neglect involving Resident #4, specifically regarding treatment by a certified nursing assistant (CNA #1).
Complaint Details
The complaint investigation was substantiated. Resident #4 reported being left naked and soiled in bed by CNA #1, who was suspended pending investigation and later terminated. The facility implemented staff re-education and monitoring to prevent recurrence.
Findings
The facility failed to ensure residents were treated with dignity and respect, free from neglect, and provided adequate assistance with activities of daily living for Resident #4. CNA #1 was found to have left Resident #4 naked and soiled in bed and was suspended and later terminated following the investigation.
Deficiencies (3)
F 0557: The facility failed to honor the resident's right to be treated with respect and dignity and to retain and use personal possessions for Resident #4.
F 0600: The facility failed to protect Resident #4 from neglect, including leaving them soiled and unattended, resulting in minimal harm or potential for actual harm.
F 0677: The facility failed to provide care and assistance with activities of daily living for Resident #4, who was dependent on staff for toileting hygiene.
Report Facts
Residents affected: 1
Residents reviewed: 4
Resident census: 78
Duration of interrupted care: 30
Duration of interrupted care: 45
Shift overlap: 30
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 3
Date: Jan 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, discharge data submission, and catheter care in the nursing facility.
Findings
The facility failed to submit discharge assessments to CMS within seven days for two residents, failed to ensure accurate coding of assessments for one resident, and failed to obtain an order for suprapubic catheter care for one resident. The administrator reported 75 residents resided in the facility during the inspection.
Deficiencies (3)
F 0640: The facility failed to submit discharge assessments to CMS within seven days of completion for two residents (#64 and #66).
F 0641: The facility failed to ensure assessments were coded accurately for one resident (#75).
F 0690: The facility failed to obtain an order for suprapubic catheter care for one resident (#46).
Report Facts
Residents: 75
Sampled residents: 18
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS coordinator | Reported on assessment submission and accuracy issues. | |
| LPN #1 | Noted absence of order for catheter care during preparation. | |
| DON | Reported missing catheter care order after resident's hospital return. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
The inspection was conducted due to allegations of abuse involving two residents (#3 and #4) at the facility.
Complaint Details
The complaint was substantiated. Two staff members were terminated and reported to the appropriate registries. The facility conducted a thorough investigation and implemented abuse education and monitoring to prevent recurrence.
Findings
The facility failed to ensure residents were free from abuse for two of three residents sampled. Two staff members (CNA #4 and LPN #4) were found responsible for neglect and abuse and were terminated. The facility conducted investigations, reported the incidents to appropriate authorities, and provided abuse education to staff.
Deficiencies (1)
F 0610: The facility failed to ensure residents were free from abuse for two residents. Resident #3 was left soiled and stuck between the bed and wall, and Resident #4 did not receive hydration, medication, or dressing changes as documented.
Report Facts
Residents identified: 75
Date of abuse incident: Oct 5, 2024
Date of abuse incident: Oct 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Staff member who left Resident #3 soiled and stuck in bed; terminated and reported to nurse aide registry. | |
| LPN #4 | Staff member who failed to provide hydration, medication, and dressing changes to Resident #4; terminated and reported to licensing board. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The inspection was a complaint investigation triggered by allegations that the facility failed to ensure residents were free from physical, verbal, and psychosocial abuse, and misappropriation of property.
Complaint Details
The complaint alleged that the center failed to ensure residents were not physically, verbally, or psychosocially abused, and failed to ensure residents were free from misappropriation of property. The investigation included observations, interviews with residents, family, and staff, and review of records. No deficiencies were cited.
Findings
The complaint investigations conducted on January 2 and 3, 2025, found no deficiencies. Observations, interviews, and record reviews were conducted, and no violations were cited.
Report Facts
Facility Census: 73
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
The visit was a complaint investigation conducted due to allegations that the facility failed to protect residents from physical abuse by staff members.
Complaint Details
The complaint alleged failure to protect residents from physical abuse by staff members. The investigation was unannounced and included observations, interviews, and record reviews. No deficiencies were cited.
Findings
The investigation found no deficiencies. Residents were observed to be clean and groomed, staff interacted respectfully, and staffing levels met state requirements. No abuse was substantiated.
Report Facts
Facility Census: 47
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clorissa Nubine | Enforcement Analyst | Author of the report and contact for questions |
| Angela Green | Administrator | Facility administrator addressed in the report |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Oct 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse of a resident.
Complaint Details
The complaint investigation substantiated abuse of Resident #2 by CNA #2. The CNA was suspended and terminated. Resident #2 was moved to another room per their request. Staff received in-service training on abuse.
Findings
The facility failed to prevent abuse for one of three sampled residents. The abuse was investigated, resulting in suspension and termination of the involved CNA, relocation of the resident, and staff in-service training on abuse.
Deficiencies (1)
F 0610: The facility failed to prevent abuse for one resident who reported being hit by a CNA, had the call buzzer taken away, and was left without assistance all night.
Report Facts
Residents present: 71
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: May 22, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the involuntary discharge of a resident from the facility.
Complaint Details
The complaint involved one resident who was involuntarily discharged. The facility was found to have failed to ensure the resident was not discharged without adequate reason and documentation. The complaint was substantiated.
Findings
The facility failed to ensure that a resident was not involuntarily discharged without adequate reason and proper documentation. The resident was discharged despite the spouse's change of mind and was not allowed to remain in the facility because the transfer was already in process.
Deficiencies (1)
F 0622: The facility failed to not transfer or discharge a resident without an adequate reason and proper documentation. Resident #1 was discharged despite the spouse's objection and was not allowed to remain in the facility.
Report Facts
Residents present: 77
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Dec 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation to determine if the facility protected residents from abuse.
Complaint Details
The complaint alleged that the facility failed to protect residents from abuse. The investigation was unannounced and included interviews, observations, and record reviews. No deficiencies were cited, indicating the complaint was not substantiated.
Findings
The investigation found no deficiencies. The facility was observed to be clean, staff were providing care appropriately, and records including policies, employee training, and resident incident reports were reviewed with no issues identified.
Report Facts
Facility Census: 59
Sample Size: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
Annual inspection survey of Saint Simeons Episcopal Home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 5
Date: Jun 6, 2023
Visit Reason
A relicensure survey was conducted on June 5-6, 2023, to assess compliance with state licensure requirements for the assisted living center.
Findings
The survey identified multiple deficiencies including failure to ensure food was stored, prepared, and served in a sanitary manner; improper disposal of potentially hazardous leftovers; incomplete resident assessments lacking required signatures and interviews; and direct care staff lacking required first aid and CPR training.
Deficiencies (5)
Failed to ensure food was stored, prepared, and served in a sanitary manner, including uncovered trash cans and lack of beard guards for staff with facial hair.
Failed to ensure leftovers which were potentially hazardous foods were disposed of within 24 hours and non-potentially hazardous foods within 48 hours.
Failed to ensure resident assessments were coordinated and signed by a registered nurse or the resident's personal physician for two of eight sampled residents.
Failed to ensure comprehensive assessments included a personal interview between the resident or representative and the person completing the form for two of eight sampled residents.
Failed to ensure direct care staff were trained in first aid and cardiopulmonary resuscitation for four of five recently hired staff members.
Report Facts
Residents: 47
Recently hired staff without CPR/first aid training: 4
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that the facility failed to have a properly and consistently functioning call system.
Complaint Details
Allegation: The facility failed to have a properly and consistently functioning call system. The allegation was unsubstantiated (US) after investigation.
Findings
The investigation found the allegation to be unsubstantiated. The facility was clean, residents were well cared for, and the call light system was functioning properly with no failures reported. Staff responded timely to call lights and residents' needs were met.
Report Facts
Total Residents: 48
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anita Newman | LPN, CHFC | Signed the report and noted in the determination summary |
Inspection Report
Routine
Census: 83
Deficiencies: 4
Date: Aug 18, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to dialysis care, medication administration, drug labeling, and infection prevention and control at Saint Simeons Episcopal Home.
Findings
The facility failed to ensure proper coordination of dialysis services for one resident, had significant medication errors and labeling issues for another resident, and did not maintain proper infection tracking and trending for three months. The deficiencies were noted with minimal harm or potential for actual harm.
Deficiencies (4)
F 0698: The facility failed to coordinate dialysis services for one resident requiring dialysis, resulting in delayed surgical planning for fistula replacement.
F 0760: The facility failed to ensure residents were free from significant medication errors for one resident during medication administration observation.
F 0761: The facility failed to correctly label stored medications for one resident, resulting in a significant medication error.
F 0880: The facility failed to track and analyze infection data for trends for three months, compromising infection prevention efforts.
Report Facts
Residents receiving medications: 83
Residents reviewed for dialysis services: 1
Residents reviewed for medication errors: 5
Residents affected by deficiencies: 1
Residents affected by medication error: 1
Months of infection data not tracked: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in dialysis coordination deficiency for failure to follow up on nephrologist's order. |
| ADON #1 | Assistant Director of Nursing | Interviewed regarding dialysis coordination and medication administration processes. |
| CMA #1 | Certified Medication Aide | Observed and interviewed regarding medication administration errors. |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding failure to track and trend infection data. |
| Administrator | Facility Administrator | Provided census data and was interviewed about infection control tracking. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Jun 8, 2021
Visit Reason
The visit was conducted as a complaint investigation based on allegations regarding residents' right to visitors of choice and infection control practices related to COVID-19.
Complaint Details
Two allegations were investigated: 1) failure to ensure residents' right to visitors of choice, and 2) failure to follow proper infection control practices related to COVID-19. Both allegations were unsubstantiated.
Findings
The investigation found no deficiencies; both allegations were unsubstantiated, and no further action was required.
Report Facts
Total Census: 59
Sample Residents Interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Stagner | Long Term Care Enforcement Reviewer | Signed the complaint investigation report |
| Mary Cooper | RN/CHFS | Signed the completion of the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Date: Aug 13, 2019
Visit Reason
Surveyors attempted to investigate a complaint at the facility on August 13, 2019, related to an administrative error concerning the nursing facility portion of the care center. The complaint was sent to the wrong department and investigated at the correct facility type later.
Complaint Details
Complaint #OK53870 was investigated but was sent to the wrong department. The complaint concerned the nursing facility portion, not the assisted living portion of the care center.
Findings
An abbreviated survey was conducted on August 13, 2019, to investigate the complaint. No action was needed on the assisted living portion of the care center as the complaint pertained to the nursing facility portion. The complaint was found to have been sent to the wrong department.
Report Facts
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sue Davis | Enforcement Coordinator | Signed letter regarding complaint investigation |
Inspection Report
Renewal
Census: 68
Deficiencies: 2
Date: Apr 11, 2019
Visit Reason
A re-licensure survey was conducted from April 9 through April 11, 2019, to assess compliance with state licensure requirements for the assisted living center.
Findings
Deficiencies were found related to food storage, preparation and service, specifically that 3 of 9 sampled kitchen staff lacked documented food service training prior to food preparation. Additionally, the facility failed to initiate fingerprint-based national background checks for 3 of 9 sampled employees upon hire. The facility submitted an acceptable plan of correction and was found to be in substantial compliance by May 17, 2019.
Deficiencies (2)
Failed to ensure 3 of 9 sampled kitchen staff had documented evidence of food service training prior to food preparation.
Failed to initiate fingerprint-based national background checks for 3 of 9 sampled employees upon hire.
Report Facts
Census: 68
Employees sampled: 9
Employees lacking training documentation: 3
Employees sampled for background check: 9
Employees without background check: 3
Survey dates: 2019-04-09 to 2019-04-11
Plan of correction completion date: May 17, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Green | Administrator | Named as facility administrator in relation to findings and plan of correction |
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed acceptance letter of plan of correction |
| Sue Davis | Enforcement Coordinator | Signed letter regarding informal dispute resolution process and revisit findings |
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