Tulsa Center For Rehabilitation And Healthcare

Based on observation, record review and interview the facility failed to ensure medications were secure for 1 of 3 carts on the Southeast Hall.

The DON identified 108 residents resided in the facility.

Findings:On 08/20/25 at 10:47 a.m., a green capsule in a plastic medication cup was observed sitting on top of the medication cart unattended on the Southeast Hallway. A Policy dated 04/2018, titled Medication Storage In The Facility, read in part, The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 08/20/25 at 10:54 a.m., LPN # 2 stated they had left the medication on top of the medication cart. LPN # 2 stated they had intended to administer it to a resident but forgot.

They stated leaving the medication unattended on the cart could result in the wrong resident taking the medication and could cause a medication error.

They stated it should not have been left out on top of the cart and should have been secured inside the cart.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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