Leisure Village Health Care: Family Notification Failures - OK
Leisure Village Health Care Center failed to notify families of significant health changes for residents, despite a facility policy requiring such communication, according to a federal inspection report.
The violation affected at least two residents among four cases reviewed by inspectors at the 80-bed facility.
Resident #4 developed nausea in December 2024 and received a new anti-nausea medication. The facility notified the physician but not the resident's representative, according to nurse notes reviewed by inspectors.
Two months later, the same resident had elevated blood sugar levels indicating diabetes. The physician prescribed metformin, a diabetes medication, and diagnosed type II diabetes mellitus. Again, nursing notes showed no family notification of the abnormal lab results, new medication, or diabetes diagnosis.
The resident had intact cognition, scoring 15 on a mental status assessment in June 2025, indicating clear thinking ability.
When inspectors interviewed the resident's representative on September 9, they learned the facility had contacted the family only once since the resident's admission in October 2020 — nearly five years earlier.
A second resident, #9, fell from bed onto a fall mat in May 2025. Nursing notes indicated the physician and director of nursing were notified, along with a family member.
But when inspectors spoke with that family member, they learned the facility never told them about the fall.
The facility's own policy, revised in February 2025, required notification of both the attending physician and resident representative for any change in condition. The policy cited federal and state regulations as the basis for this requirement.
Staff gave conflicting explanations for the notification failures when questioned by inspectors.
LPN #1 told inspectors that resident representatives should be notified of any significant change to a resident's condition. However, the nurse added that if residents were cognitively intact, staff "did not always have to notify family."
LPN #2 stated representatives should be notified whenever residents were sent to the hospital, had medication changes, or experienced any other significant event.
The director of nursing acknowledged that representatives should be notified of significant changes but said it was not always necessary to notify families of cognitively intact residents unless the representative specifically requested notification.
This interpretation contradicted the facility's written policy, which made no distinction between cognitively intact and impaired residents regarding family notification requirements.
The inspection occurred following a complaint about the facility's practices. Federal regulations require nursing homes to immediately inform residents, their doctors, and family members of situations that affect the resident, including injuries, health decline, and room changes.
Resident #4's case illustrated how families can remain unaware of major health developments. The resident's diabetes diagnosis represented a significant new medical condition requiring ongoing medication management and monitoring. Type II diabetes can lead to serious complications including heart disease, kidney damage, and vision problems without proper treatment.
The medication prescribed, metformin, helps control blood sugar levels but requires monitoring for side effects and effectiveness. Family members often play crucial roles in supporting medication compliance and watching for concerning symptoms.
For Resident #9, the fall represented a safety incident that families typically want to know about immediately. Falls can indicate underlying health changes, medication effects, or environmental hazards requiring attention.
The facility's inconsistent staff understanding of notification requirements suggested a broader problem with policy implementation. While the written policy clearly required family notification, nursing staff operated under different interpretations of when such notification was necessary.
The distinction some staff made between cognitively intact and impaired residents had no basis in the facility's written policy or federal regulations. Both require family notification regardless of residents' mental status.
Resident #4's representative experienced the practical impact of these notification failures. Despite their relative living at the facility for nearly five years and developing a significant new medical condition, they learned about the diabetes diagnosis only when federal inspectors investigated the facility's practices.
The case highlighted how communication breakdowns can leave families uninformed about their relatives' health status, potentially affecting their ability to participate in care decisions or provide appropriate support.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting some residents at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Leisure Village Health Care Center from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Leisure Village Health Care Center in Tulsa, OK was cited for violations during a health inspection on September 9, 2025.
The violation affected at least two residents among four cases reviewed by inspectors at the 80-bed facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.