Maplewood Care Center: Treatment Order Failures - OK
Resident #1 weighed 273.81 pounds during a September 23 hospital stay. When readmitted to the hospital on October 22, the patient weighed 291.45 pounds. The 6% weight gain in one month contributed to what hospital records described as "congestive heart failure exacerbation."
The resident's hospital admission notes documented elevated troponin levels, indicating heart muscle damage, and elevated BNP levels, a hormone released when the heart experiences stress from conditions like heart failure. Doctors also found worsening left-sided atelectasis, a partial or complete collapse of lung tissue.
Tulsa Center for Rehabilitation and Healthcare had not implemented daily weight monitoring despite the resident's heart condition.
Licensed practical nurse #1 told inspectors on October 24 that facility protocol required daily weights "at the same time" for residents with congestive heart failure or bilateral edema. The nurse said staff "would expect to obtain daily weights on residents with CHF."
But the Director of Nursing contradicted this standard. She initially told inspectors that "best practice for monitoring fluid overload was intake and output monitoring and weights" and that the facility "would typically obtain weights for residents who had a diagnosis of CHF."
Twenty minutes later, the same director changed her explanation. She claimed the facility "did not show a diagnosis of CHF for Resident #1 and did not have a justified reason to obtain daily weights or intake and output volumes."
The facility's Advanced Practice Registered Nurse acknowledged the monitoring failure. She told inspectors that daily weights "probably still should have been obtained" for the resident. The APRN said best practice for heart failure monitoring "would depend on how controlled they were, but if they were not controlled then they would order daily weights then weekly weights, and trend shortness of breath or edema."
The APRN had noticed the resident's weight gain but "did not feel it was fluid overload." She explained that the resident had low blood pressure and "they did not have room to go up on their diuretic medications."
The resident also developed swelling and drainage that required antibiotic treatment. The APRN said she "was made aware of the swelling and draining and that was when they ordered antibiotics."
Federal nursing home regulations require facilities to monitor residents for changes in condition and provide necessary medical care. Daily weight monitoring serves as a critical early warning system for heart failure patients, as rapid weight gain often indicates dangerous fluid retention that can lead to hospitalization or death.
The inspection found the facility failed to follow its own stated protocols for heart failure monitoring. While staff described daily weights as standard practice for residents with congestive heart failure, they provided no weights for Resident #1 during the month when the patient gained 18 pounds.
The resident's case illustrates how inconsistent monitoring can miss deteriorating conditions in vulnerable patients. The 18-pound weight gain represented a significant change that, if detected early through daily weighing, might have prompted intervention before emergency hospitalization became necessary.
Hospital records showed the resident required treatment for multiple complications related to the heart failure exacerbation, including lung collapse and elevated cardiac stress markers. The facility's failure to track daily weights meant staff missed a month of progressive weight gain that signaled worsening heart failure.
The Director of Nursing's shifting explanations during the inspection suggested confusion about the facility's own monitoring standards. Her initial acknowledgment that daily weights represented best practice for heart failure patients contradicted her later claim that the resident didn't qualify for such monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tulsa Center For Rehabilitation and Healthcare from 2025-11-21 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
Tulsa Center for Rehabilitation and Healthcare in TULSA, OK was cited for violations during a health inspection on November 21, 2025.
Resident #1 weighed 273.81 pounds during a September 23 hospital stay.
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.