Summary of Facility Monitoring
Facility Name: TULSA BOYS HOME Date: 9/19/2026 Time: 9:12:25 PM
Case Number: K850000065



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Program Name TULSA BOYS HOME Director Kyle Shinn
Location 2727 S 137 W AVE

SAND SPRINGS, Oklahoma 74063 		E-Mail Address kcallen@tbhinc.org
Program Phone (918) 245-0231 County of Facility Tulsa
Program Type Residential Program Subtype Residential
Residential Specialist Name Christy Haws Residential Specialist
Phone Number 		(918) 348-9804
Capacity 12 Services Provided


Monitoring Summary since 9/19/2023
Listed below are the non-compliances OBSERVED during a visit. The regulation, its description, the non-compliance observed according to the regulation, and a plan of corrective action are all provided. The column "NRS" indicates Numerous, Repeated and/or Serious non-compliances with Licensing Requirements.
Visit Date 7/16/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(b)(1)(B)(vi)names and dated signatures of those participating in service plan development.There were signatures missing on service plans in both files reviewed.Signatures will be obtained on current forms and in the future signatures will be collected or documentation of a request for signature will be maintained in the file. 07/24/2026No
340:110-3-153.1(l)Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment.One new personnel did not have orientation completed within 30 calendar days of employment.Orientation will be completed within 30 day of employment. 07/16/2026No

Visit Date 2/26/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(a)(6)Residents receive a medical examination by a licensed health care professional within 60-calendar days prior to admission or within 30-calendar days following admission. However, a documented medical exam performed within the 12 months prior to admission is acceptable when a resident is transferred from another licensed program.One resident did not receive his medical exam timely.Residents will receive medical exams timely. 02/26/2026No
340:110-3-153.1(g)(1)References. The program obtains three references for personnel prior to employment. Copies are maintained in the employee's personnel record.6 personnel did not have documentation of references being completed prior to hire.References will be obtained prior to hire 02/26/2026No
340:110-3-153.1(g)(3)Performance evaluation. A written performance evaluation is updated at least annually and maintained in the employee's personnel record.There was not documentation of 4 performance evaluations for 2025.Performance evaluations will be obtained annually. 03/07/2026No
340:110-3-153.1(l)Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment.10 personnel did not have documentation of orientation.Orientation will be completed within 30 days of employment. 02/26/2026No
340:110-3-153.1(m)Personnel professional development. Professional development the program schedules is obtained on or after personnel's employment date. Personnel meet professional development requirements in (1) through (7) of this subsection13 personnel did not meet professional development requirements.Personnel will meet annual professional development requirements. 02/26/2026No
340:110-3-153.1(o)(2)(A)an OKDHS-provided personnel information sheet, completed for each personnel upon employment and submitted to Licensing within two weeks of his or her employment;Licensing did not receive2 personnel information sheets within 2 weeks of employment.Licensing will receive personnel sheets within 2 weeks of employment. 02/26/2026No

Visit Date 10/23/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(j)Sanitation and safety. All areas are clean, sanitary, and hazard-free.Room 5 broken tiles between toilet and sink.Tiles will be repaired. 10/31/2025No

Visit Date 6/13/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.#6 sink was grimy and had caked on toothpaste, #5 broken tile on the wall between the toilet and the sink, #8 had a hole in the showerItems were cleaned during the visit. Shower and tile will be repaired. 06/17/2025No
340:110-3-164(10)(F)Non-food contact surfaces of all equipment, including tables, counters, and shelves, are cleaned as often as necessary to keep them free of accumulations of dust, dirt, food particles, and other debris.A substance had spilled on several areas of the refrigeratorRefrigerator will be cleaned. 06/13/2025No

Visit Date 3/25/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-164(4)(C)A thermometer is located in a conspicuous place in each refrigerator and freezer.There was no thermometer in the freezerThermometer will be placed in the freezer. 03/25/2025No
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.#1 shower has soiled areas in the corners #2 Toilet has dried feces in the bowl #5 toilet has dried ring in toilet bowl #8 shower base has brown soiled areas in the back #7 shower has large cracked area on the wall underneath faucet headBathrooms will be maintained in a clean and sanitary condition 03/25/2025No

Visit Date 10/17/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(b)(2)(C)(v)names and dated signatures of review participants.One treatment plan was missing a program director signature on 7/19/2024 plan and a resident signature on 9/18/2024 plan.Required signatures will be on treatment plans. 10/17/2024No
340:110-3-164(4)(C)A thermometer is located in a conspicuous place in each refrigerator and freezer.The refrigerator and freezer did not have thermometers.Corrected during the visit. Thermometers were obtained from the cafeteria and placed in the refrigerator and the freezer. 10/17/2024No

Visit Date 6/27/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(b)(1)(B)(vi)names and dated signatures of those participating in service plan development.There were no parent signatures in 2 of the files reviewed on the most current treatment plans and no documentation of the signature being requested.Files will have signatures or documentation of attempt to receive signatures 06/27/2024No

Visit Date 2/23/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-164(10)(E)Cooking devices are cleaned as often as necessary and are free of encrusted grease deposits and other soils.Oven was found to be greasy and dirty.Oven will be cleaned 02/26/2024No
340:110-3-153.1(m)(3)(E)When residents are in care on the facility premises or on a program-sponsored field trip, at least one personnel is present with current age-appropriate first aid and cardio-pulmonary resuscitation (CPR) documentation. All other child care personnel obtain and maintain age-appropriate first aid and CPR within 90-calendar days of employment. CPR and first aid training are conducted by a certified instructor from an OKDHS-approved source.2 personnel did not have current CPR/FAPersonnel will maintain CPR/FA 03/01/2024No
340:110-3-153.1(o)(2)(A)an OKDHS-provided personnel information sheet, completed for each personnel and submitted to Licensing within two weeks of his or her employment;1 personnel information sheet was not submitted to licensing within 2 weeks of employment.Personnel information sheets will be submitted to licensing within 2 weeks of employment. 02/23/2024No

Visit Date 9/28/2023 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.Room 3 had a urine ring in the toilet, Room 8 had a ring in the toilet and feces on the wall by the toilet paper holder. Rooms 1, 7 and 10 had grime towards the bottom of the showers.Bathrooms will be cleaned and maintained in a sanitary manner. 09/28/2023No
340:110-3-165.1(1)Fire drills. Residents participate in fire drills at least six times annually on a bi-monthly basis with at least two drills conducted at night during sleeping hours.The last documented fire drill was 4/5/2023.Fire drills will be documented and maintained on a bi-monthly basis. 09/30/2023No




Complaint Summary since 9/19/2023
No data on file