Summary of Facility Monitoring
Facility Name: EAGLE LODGE Date: 10/6/2026 Time: 8:09:22 PM
Case Number: K850051566



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Program Name EAGLE LODGE Director John McKain
Location 2727 South 137th West Ave

Sand Springs, Oklahoma 74063 		E-Mail Address mmurphy@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 10/6/2023
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 8/20/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(n)Fire safety. The program complies with the state fire marshal's office regulations for construction and fire safety and is inspected annually by the state fire marshal's office or its designee.The fire inspection for the program was expired.The fire inspector's office has been contacted. They were told the inspector is on leave. The program will attempt to schedule inspection by the end of the month. 08/31/2026No
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.One new personnel had references dated after hire.References are to be obtained prior to hire 08/20/2026No

Visit Date 3/12/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
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.Reference will be completed prior to hire 03/12/2026No
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 performance evaluations for 4 staff.Performance evacuations will be completed annually 03/12/2026No
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 completing orientation.Orientation will be completed within 30 days of employment. 03/12/2026No
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 beet professional development requirements 03/12/2026No
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 receive 2 personnel information sheets within 2 weeks of employment.Personnel information sheets will be submitted to licensing within 2 weeks of employment. 03/12/2026No
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 have a medical exam completed timely.Medical exams will be completed within 30 days of admission. 03/12/2026No

Visit Date 11/21/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
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.One personnel did not have references completed prior to hire and one personnel did not have documentation of references.References will be completed prior to hire. 11/24/2025No

Visit Date 7/24/2025 Visit Type Full Purpose of Visit Periodic
No non-compliances observed

Visit Date 3/25/2025 Visit Type Full Purpose of Visit Periodic
No non-compliances observed

Visit Date 11/22/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-165(6)Maintenance of equipment. All safety equipment, including emergency lighting, commercial stove hoods, sprinkler systems, and any other required safety equipment, is maintained in compliance with current codes or manufacturer's instructions.The cover of the exit light above the desk was missing.The cover for the exit light was replaced during the visit. 11/22/2024No
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.5 new personnel did not have documentation of references.Documentation of references will be obtained prior to hire. 11/25/2024No
340:110-3-153.1(l)Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment.There were 3 personnel that had documentation of orientation prior to hire.Orientation will be completed after employment date. 11/22/2024No

Visit Date 7/11/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-157(n)Fire safety. The program complies with the state fire marshal's office regulations for construction and fire safety and is inspected annually by the state fire marshal's office or its designee.The last fire inspection was 6/28/2023.Fire marshal will be contacted to schedule inspection. 07/11/2024No

Visit Date 3/14/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
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/FAClass is scheduled for 3/20/2024. Training will be maintained. 03/20/2024No
340:110-3-157(j)Sanitation and safety. All areas are clean, sanitary, and hazard-free.The oven was dirty and greasy.Oven will be cleaned. 03/18/2024No

Visit Date 10/19/2023 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-163(1)(A)Exterior and interior surfaces are maintained in sound condition and free of holes, peeling paper, and paint.Room B has a large hole in the wall.The hole will be patched. 10/22/2023No
340:110-3-164(4)Food protection. Foods are covered and protected from contamination while being stored, prepared, displayed, or transported.There was an uncovered bowl of watermelon in the refrigerator.Any food in the refrigerator will be covered. 10/19/2023No
340:110-3-165.1(3)Fire and tornado drill records. Facilities maintain fire and tornado drill logs.The last document fire and tornado drills were conducted 6/16/2023.Documentation of drills will be available to licensing. 10/19/2023No




Complaint Summary since 10/6/2023
No data on file