Summary of Facility Monitoring
Facility Name: FALCON LODGE Date: 10/7/2026 Time: 9:56:19 PM
Case Number: K850051567



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Program Name FALCON LODGE Director Apryl Stansill
Location 2727 South 137th West 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 10/7/2023
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 6/25/2026 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 were no thermometers in the refrigerator or the freezer.Thermometers will be placed in the refrigerator and freezer 06/26/2026No
340:110-3-154(a)(1)(E)immunization record, medical and dental histories, including current medical problems;One file reviewed did not have documentation of immunizationsImmunizations will be obtained for resident 07/03/2026No
340:110-3-153.1(l)Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment.2 personnel did not receive orientation timely and 6 new personnel did not have documentation of orientation within 30 calendar days of employment.Orientation documentation will be collected for new employees 07/10/2026No
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 maintain current CPR/First aidPersonnel are scheduled for CPR First Aid class on 7/7/2026 07/10/2026No

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 hireReferences 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 4 performance evaluations for 2025Performance evaluations 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 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 meet annual 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 employmentPersonnel 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.2 residents did not completed medical exams timely.Medical exams will be completed within 30 days of admission 03/12/2026No
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.One toilet had a black mold ring.Toilet will be cleaned and maintained 03/13/2026No

Visit Date 1/6/2026 Visit Type Partial Purpose of Visit Other
No non-compliances observed

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 file did not have references completed timely and one personnel file did not have any references completed.References for personnel will be obtained prior to hire 11/24/2025No
340:110-3-154(a)(8)(A)resident's rights;One resident file did not have documentation of resident's rights completedDocumentation of signed resident's rights will be maintained in resident file. 11/24/2025No
340:110-3-154(a)(8)(B)grievance procedures;One resident file did not have documentation of grievances completedDocumentation of signed grievance procedures will be maintained in resident file. 11/24/2025No
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.Feces on the back of toilet and hair and grime in the sink room CBathrooms are maintained in clean and sanitary condition. 11/21/2025No

Visit Date 8/7/2025 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
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.The sink and the toilet in room C were unclean.The bathrooms will be maintained in a clean and sanitary condition 11/22/2024No
340:110-3-165(5)Fire protection equipment. Equipment is installed and maintained as required by codes adapted by the Office of the State Fire Marshal.An exit light was broken between rooms E and G.Exit light will be repaired or replaced to maintain fire marshal codes 11/26/2024No
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 referencesDocumentation 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.3 new personnel had documentation of orientation being completed prior to hire.Orientation will be completed after employment date. 11/22/2024No

Visit Date 8/21/2024 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.There was urine on the floor in room JBathroom will be maintained in a clean and sanitary manner. 08/22/2024No
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;2 personnel information sheets were not submitted to licensing within 2 weeks of employment.Personnel sheets will be submitted to licensing within 2 weeks. 08/22/2024No
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 emergency light between rooms E & G is broken.The light will be repaired or replaced 08/31/2024No

Visit Date 4/18/2024 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.Emergency light by entrance was not working.Emergency light will be repaired. 04/19/2024No

Visit Date 12/14/2023 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
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;6 personnel information sheets had not been submitted to licensing within 2 weeks of employments.Personnel information sheets will be sent to licensing within two weeks of hire. 12/14/2023No
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.bathroom H had feces on the wall.Bathroom wall be cleaned and maintained in a clean and sanitary manner 12/14/2023No
340:110-3-157(j)(1)Harmful substances and objects not essential to facility operation are prohibited on the premises. Other poisonous, flammable, or harmful materials are locked when not under adult supervision.The outlet cover was off of an outlet in room FOutlet cover need to be repaired. Request for repair has already been made. 12/14/2023No
340:110-3-154(b)(2)(C)(v)names and dated signatures of review participants.2 of the updated service plans did not have all participant signatures.Service plans will have all participants' signatures or documentation of request for signatures. 12/14/2023No




Complaint Summary since 10/7/2023
No data on file