Inspection Reports for Ash Street Place

111 SOUTH ASH, OK, 73044

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Deficiencies (last 7 years)

Deficiencies (over 7 years) 1.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

65% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/year

Deficiencies per year

8 6 4 2 0
2019
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 58 residents

Based on a August 2025 inspection.

Census over time

48 52 56 60 64 Feb 2019 Jan 2020 Nov 2023 Aug 2024 Aug 2025
Inspection Report Routine Deficiencies: 0 Nov 20, 2025
Visit Reason
The inspection was conducted as a routine survey of the Assisted Living Center to assess compliance with applicable regulations.
Findings
No deficiencies were cited during the inspection conducted on November 20, 2025.
Employees Mentioned
NameTitleContext
Clorissa NubineEnforcement AnalystSigned the inspection report.
Inspection Report Complaint Investigation Census: 58 Deficiencies: 5 Aug 28, 2025
Visit Reason
A complaint survey was conducted due to multiple allegations including failure to provide care according to physician orders, insufficient staffing, inadequate meal provision, medication administration issues, infection control lapses, and failure to ensure resident safety and supervision.
Findings
The facility was found deficient in providing adequate memory care activities, maintaining kitchen cleanliness, ensuring sufficient staffing to meet resident care and evacuation needs, timely incident reporting, and medication availability and administration. Deficiencies were cited for failure to provide planned cognitive activities for memory care residents, kitchen floor cleanliness and ice machine maintenance, insufficient staff coverage especially during night shifts, delayed incident reporting, and missing medications for a resident.
Complaint Details
The complaint investigation included multiple allegations such as failure to provide care according to physician orders, insufficient staffing, failure to provide meals three times daily, failure to administer antibiotics as ordered, inadequate infection control during medication administration, failure to prevent falls, failure to ensure food served under sanitary conditions, failure to follow medication administration policies, failure to ensure advance directives were honored, and failure to submit timely incident reports.
Severity Breakdown
C 328: 1 C 391: 1 C 910: 1 C1911: 1 C1922: 1
Deficiencies (5)
DescriptionSeverity
Residents in the memory care unit did not receive activity programs to meet cognitive needs as described in the residency agreement.C 328
Kitchen floors were not clean and free of debris; ice machine filter was not changed and cleaned by the date posted.C 391
Insufficient staffing to meet resident care needs and evacuation requirements.C 910
Failure to submit incident report within one business day and final report within five business days for a reportable incident.C1911
Medications were not available for administration for one resident during the medication pass.C1922
Report Facts
Facility Census: 58 Call light response times over 15 minutes: 55 Staffing counts: 3 Staffing counts: 2 Residents in memory care unit: 14 Residents bedbound: 2 Residents chairfast: 4 Residents with dementia: 14 Residents needing special evacuation assistance: 5 Medications not available: 6
Employees Mentioned
NameTitleContext
Melinda HawkinsAdministratorNamed in multiple correspondence and plan of correction documents
Clorissa NubineEnforcement AnalystSigned enforcement and correspondence letters
Inspection Report Renewal Capacity: 37 Deficiencies: 0 Apr 10, 2025
Visit Reason
This document serves as a renewal license issued to Ash Street Place, L.L.C., an assisted living center, authorizing it to conduct and maintain operations at the specified location.
Findings
The license renewal certifies that Ash Street Place meets the provisions of the Oklahoma Statutes and rules adopted by the State Board of Health, allowing continued operation with a maximum capacity of 37 beds.
Inspection Report Deficiencies: 0 Nov 27, 2024
Visit Reason
The inspection was a State Licensure survey conducted at the facility to identify deficiencies related to regulatory compliance.
Findings
Deficiencies were found during the survey that represented the potential for more than minimal harm. The facility is required to submit a plan of correction to address these deficiencies before penalties are assessed.
Inspection Report Renewal Census: 57 Deficiencies: 2 Aug 15, 2024
Visit Reason
A relicensure survey was conducted from August 14, 2024 through August 15, 2024 to assess compliance with licensure requirements for Arbor House Assisted Living of Midwest City.
Findings
The facility was found deficient in staff qualifications, specifically failure to ensure one staff member (#2) was trained in first aid, CPR, and abuse training within 90 days of employment. The facility submitted a plan of correction which was accepted, and a revisit confirmed substantial compliance effective September 30, 2024.
Severity Breakdown
SS=E: 2
Deficiencies (2)
DescriptionSeverity
Failed to ensure staff were trained in first aid and cardiopulmonary resuscitation for one (#2) of five staff reviewed.SS=E
Failed to ensure employees received abuse training within 90 days of employment for one (CNA #2) of five staff reviewed.SS=E
Report Facts
Facility Census: 57 Deficiencies cited: 2
Inspection Report Renewal Capacity: 65 Deficiencies: 0 Feb 6, 2024
Visit Reason
This document is a license renewal for the assisted living center Arbor House Assisted Living of Midwest City, certifying the facility to continue operation.
Findings
The document certifies that LGD Midwest City Opco, LLC is licensed to conduct and maintain an assisted living center with a maximum capacity of 65 beds. It is issued pursuant to Oklahoma statutes and state board of health regulations.
Report Facts
Maximum licensed beds: 65
Inspection Report Complaint Investigation Census: 53 Deficiencies: 2 Nov 9, 2023
Visit Reason
A complaint investigation was conducted due to allegations that the facility failed to ensure medications were administered according to physicians' orders and failed to ensure qualified staff to provide care for residents.
Findings
The investigation found deficiencies in medication administration, including failure to administer medication according to physician's orders and untimely medication administration. The facility also failed to ensure qualified staff provided care. The facility was given an opportunity to correct these deficiencies.
Complaint Details
The complaint investigation was initiated on 2023-11-08 due to allegations that the facility failed to ensure medications were administered according to physicians' orders and failed to ensure qualified staff to provide care. The investigation included observations, interviews, and record reviews. The deficiencies cited represented potential for more than minimal harm but no actual harm was identified.
Severity Breakdown
Level D: 2
Deficiencies (2)
DescriptionSeverity
Failed to administer medication according to the physician's order for one resident.Level D
Failed to maintain an accurate written record of medications administered, including timely administration.Level D
Report Facts
Residents present: 53 Sample size: 10 Deficiencies cited: 2 Plan of correction completion date: Dec 16, 2023 Revisit date: Feb 9, 2024 Correction effective date: Nov 27, 2023
Employees Mentioned
NameTitleContext
Andrea PickettAdministratorNamed as facility administrator and recipient of inspection correspondence
Lisa CalvinEnforcement AnalystSigned enforcement division letter related to complaint investigation
Tempal KillmanAdministrative Assistant IISigned letter accepting plan of correction
Clorissa NubineEnforcement AnalystSigned letter regarding complaint revisit and correction verification
DONDirector of NursingInterviewed regarding medication administration and findings
CMA #1Certified Medication AideInterviewed and observed during medication pass related to medication availability and administration
RCCResident Care CoordinatorInterviewed regarding medication reordering process
Inspection Report Routine Deficiencies: 0 May 30, 2023
Visit Reason
The inspection was conducted as a routine survey of the Assisted Living Center to assess compliance with applicable regulations.
Findings
No deficiencies were cited during the inspection conducted at the Assisted Living Center.
Inspection Report Renewal Capacity: 65 Deficiencies: 0 Feb 22, 2023
Visit Reason
This document is a renewal license issued to Arbor House of Midwest City, L.L.C. to conduct and maintain an Assisted Living Center.
Findings
The license certifies that the facility meets the requirements to operate as an Assisted Living Center with a maximum capacity of 65 beds. No deficiencies or violations are noted in this document.
Report Facts
Maximum licensed capacity: 65
Inspection Report Complaint Investigation Deficiencies: 0 Apr 25, 2022
Visit Reason
The inspection was conducted as a complaint investigation at the Assisted Living facility.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint investigation conducted with no deficiencies cited.
Inspection Report Renewal Capacity: 37 Deficiencies: 0 Apr 12, 2022
Visit Reason
This document is a license renewal issued to Ash Street Place, L.L.C. for an Assisted Living Center, certifying the facility to conduct and maintain operations as an assisted living center.
Findings
The document certifies the renewal of the facility's license with a maximum capacity of 37 beds, effective from April 12, 2022, through April 11, 2025.
Report Facts
Maximum licensed beds: 37
Inspection Report Renewal Capacity: 37 Deficiencies: 0 Apr 1, 2021
Visit Reason
This document is a license renewal issued to Ash Street Place, L.L.C. for operating an Assisted Living Center, certifying the facility's license renewal status.
Findings
The license certifies that Ash Street Place is authorized to conduct and maintain an Assisted Living Center with a maximum capacity of 37 beds. The license is effective from 04/12/2021 through 04/11/2022.
Report Facts
Maximum licensed beds: 37
Notice Capacity: 65 Deficiencies: 0 Jan 7, 2021
Visit Reason
This document serves as a license renewal for Arbor House Assisted Living of Midwest City, authorizing the facility to conduct and maintain an assisted living center.
Findings
The license is issued pursuant to Oklahoma statutes and regulations by the State Board of Health, valid from 11/12/2020 to 11/11/2021.
Report Facts
Total licensed capacity: 65
Inspection Report Routine Deficiencies: 0 Jun 17, 2020
Visit Reason
The inspection was a COVID-19 Special Focus Infection Control Survey conducted on June 17, 2020.
Findings
No deficiencies were cited during the COVID-19 Special Focus Infection Control Survey at Ash Street Place.
Inspection Report Renewal Capacity: 37 Deficiencies: 0 Jun 8, 2020
Visit Reason
This document is a renewal license issued to Ash Street Place, an assisted living center, certifying the facility to conduct and maintain operations.
Findings
The license certifies that Ash Street Place meets the requirements to operate as an assisted living center with a maximum capacity of 37 beds. No deficiencies or violations are noted in this document.
Report Facts
Maximum licensed beds: 37
Inspection Report Complaint Investigation Census: 54 Deficiencies: 1 Jan 14, 2020
Visit Reason
A state licensure survey was conducted along with a complaint investigation triggered by allegations of improper medication administration at the facility.
Findings
The investigation substantiated deficient practice related to medication administration and accurate documentation of medication records, with potential for more than minimal harm. The facility was required to submit a plan of correction and was given an opportunity to correct deficiencies prior to penalties.
Complaint Details
The allegation that the center failed to ensure medications were properly administered was substantiated (S).
Deficiencies (1)
Description
Failed to ensure staff administered medication according to physician's orders for one resident, resulting in inaccurate medication administration records and potential for more than minimal harm.
Report Facts
Resident census: 54 Sample size: 9 Survey dates: 2020-01-11 to 2020-01-14 Report completion date: Jan 15, 2020 Plan of correction due date: Mar 20, 2020
Employees Mentioned
NameTitleContext
Melissa SwaimRNReport author and surveyor
Andrea PickettAdministratorFacility administrator named in report and correspondence
Inspection Report Renewal Capacity: 65 Deficiencies: 0 Nov 12, 2019
Visit Reason
This document is a license renewal issued to Arbor House of Midwest City, L.L.C. to conduct and maintain an Assisted Living Center.
Findings
The license certifies the facility's compliance with state regulations to operate as an Assisted Living Center with a maximum capacity of 65 beds. No deficiencies or violations are noted in this document.
Report Facts
Maximum licensed beds: 65
Inspection Report Routine Deficiencies: 0 Apr 24, 2019
Visit Reason
The inspection was conducted at the Assisted Living Center as a routine survey event identified by LVYP11.
Findings
No deficiencies were cited during the inspection conducted on April 24, 2019.
Employees Mentioned
NameTitleContext
Kay DetermanLong Term Care Enforcement ReviewerSigned the inspection report.
Inspection Report Renewal Capacity: 37 Deficiencies: 0 Mar 18, 2019
Visit Reason
This document is a license renewal issued to Ash Street Place, L.L.C. for maintaining an Assisted Living Center, certifying the facility's compliance with state regulations.
Findings
The license certifies that Ash Street Place is authorized to operate as an Assisted Living Center with a maximum capacity of 37 beds, effective from 04/12/2019 to 04/11/2020.
Inspection Report Renewal Census: 57 Deficiencies: 1 Feb 21, 2019
Visit Reason
A State Licensure survey was conducted at the assisted living facility to assess compliance with licensing requirements as part of the re-licensure process.
Findings
Deficient practice was cited related to medication staffing, specifically the failure to arrange for qualified staff to administer respiratory inhalers, resulting in potential for more than minimal harm.
Deficiencies (1)
Description
Failure to arrange for qualified staff to administer respiratory inhalers for one sampled resident, resulting in potential for more than minimal harm.
Report Facts
Resident census: 57
Inspection Report Renewal Census: 57 Deficiencies: 1 Feb 21, 2019
Visit Reason
A licensure inspection was conducted at the Assisted Living Center facility to assess compliance and identify deficiencies.
Findings
The facility failed to arrange for qualified staff to administer respiratory inhalers for one resident, allowing Medication Administration Technicians (MATs) to administer inhalers, which is against policy and regulation.
Severity Breakdown
SS=E: 1
Deficiencies (1)
DescriptionSeverity
Failed to arrange for qualified staff to administer respiratory inhalers for 1 resident; MATs administered inhalers without proper certification.SS=E
Report Facts
Resident census: 57 Deficiency count: 1
Employees Mentioned
NameTitleContext
Kay DetermanLong Term Care Enforcement ReviewerSigned the acceptance letter acknowledging the plan of correction
Andrea PickettAdministratorSigned the Plan of Correction form dated 3-12-19

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