Inspection Reports for Ashbrook Village
915 W Plato Rd, Duncan, OK 73533, United States, OK, 73533
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Inspection Report
Renewal
Census: 30
Deficiencies: 1
May 6, 2025
Visit Reason
A state licensure relicensure survey was conducted at Ashbrook Village to assess compliance with assisted living center regulations.
Findings
The survey found a deficiency related to the failure to ensure that comprehensive assessments included a personal interview between the resident or representative and the person completing the form for 3 of 8 sampled residents. No other deficiencies were cited during the relicensure survey.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure each comprehensive assessment included a personal interview between the resident or resident representative and the person completing the form for 3 of 8 sampled residents. | SS=D |
Report Facts
Facility Census: 30
Deficiencies cited: 1
Inspection Report
Renewal
Census: 30
Deficiencies: 2
Oct 19, 2023
Visit Reason
A relicensure survey was conducted from October 17, 2023 through October 19, 2023 to assess compliance with state licensure requirements for the assisted living facility.
Findings
The survey identified deficiencies including improper food storage with dry goods stored on the floor, and failure to provide residents' dining experience as advertised in marketing materials, including inconsistent menus, small portion sizes, and substitutions due to supply issues.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure dry goods were stored off the floor at least 6 inches to prevent contamination. | SS=E |
| Facility failed to ensure the resident's dining experience was provided as advertised in the marketing material, including inconsistent menus, small portion sizes, and substitutions. | SS=E |
Report Facts
Residents present: 30
Residents receiving food: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deandra Downer | Administrator | Named as facility administrator in multiple documents |
| Lisa Calvin | Enforcement Analyst | Signed enforcement letters related to the survey |
| Tempal Killman | Administrative Assistant II | Signed letter accepting plan of correction |
| Clorissa Nubine | Enforcement Analyst | Signed letter confirming correction of deficiencies after revisit |
Inspection Report
Renewal
Capacity: 39
Deficiencies: 0
Jan 9, 2023
Visit Reason
This document is a renewal license issued to HCP10C Ashbrook, LLC to conduct and maintain an Assisted Living Center named Ashbrook Village.
Findings
The license certifies that the facility meets the requirements to operate as an Assisted Living Center with a maximum capacity of 39 beds. The license is effective from 05/26/2022 and expires on 05/25/2025.
Report Facts
Maximum licensed beds: 39
Inspection Report
Complaint Investigation
Deficiencies: 7
May 12, 2022
Visit Reason
A State Licensure survey with a complaint investigation was conducted at Ashbrook Village on May 12, 2022, to investigate allegations related to medication administration, abuse/neglect policy, certified personnel administering medications, and care according to care plans.
Findings
The investigation found all allegations to be unsubstantiated with no deficient practices identified. However, the facility failed to include required admission criteria and descriptions of services in resident contracts for three sampled residents. A plan of correction was submitted and accepted, with a revisit scheduled to verify compliance.
Complaint Details
The complaint investigation included allegations that the center failed to administer medications safely and as prescribed, failed to have or implement their abuse/neglect policy, failed to ensure only certified personnel administered medications, and failed to provide care according to care plans. All allegations were found unsubstantiated.
Severity Breakdown
E: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to include admission criteria in the application for license and resident contracts for three sampled residents. | E |
| Failed to describe nursing supervision during nursing intervention in resident contracts for three sampled residents. | E |
| Failed to describe intermittent or unscheduled nursing care in resident contracts for three sampled residents. | E |
| Failed to describe medication administration in resident contracts for three sampled residents. | E |
| Failed to describe assistance with cognitive orientation in resident contracts for three sampled residents. | E |
| Failed to describe specialized services or units for Alzheimer's disease, dementia, physical disabilities, or other special needs in resident contracts for three sampled residents. | E |
| Failed to describe assistance with transfer or ambulation in resident contracts for three sampled residents. | E |
Report Facts
Deficiencies cited: 7
Investigation dates: Investigation conducted from 2022-05-10 through 2022-05-12.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Ahlborn | RN MSN Clinical Health Facility Surveyor | Named as the surveyor who completed the complaint investigation report. |
| Terry Wilkerson | Administrator | Facility administrator interviewed regarding contract deficiencies. |
| Lisa Calvin | Enforcement Reviewer/Analyst | Named as enforcement analyst and contact for enforcement process. |
| Tempal Killman | Administrative Assistant II | Signed letter accepting plan of correction. |
Inspection Report
Renewal
Capacity: 39
Deficiencies: 0
Sep 21, 2021
Visit Reason
This document is a renewal license issued to HCP10C Ashbrook, LLC for the operation of an Assisted Living Center named Ashbrook Village.
Findings
The license certifies that the facility is authorized to conduct and maintain an Assisted Living Center with a maximum capacity of 39 beds. The license is effective from 05/26/2021 and expires on 05/25/2022.
Report Facts
Maximum licensed beds: 39
Inspection Report
Abbreviated Survey
Census: 20
Deficiencies: 0
Jun 3, 2020
Visit Reason
The visit was a COVID-19 Special Focus Infection Control Survey conducted to determine if the facility was in compliance with implementing proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited during the COVID-19 Special Focus Survey.
Inspection Report
Renewal
Capacity: 39
Deficiencies: 0
Oct 9, 2019
Visit Reason
The document serves as a renewal license issued to HCP1OC Ashbrook, LLC d/b/a Ashbrook Village, certifying the facility to operate as an Assisted Living Center with a license effective from May 26, 2019, to May 25, 2020.
Findings
The Oklahoma State Department of Health accepted changes to the resident contract and service agreement submitted on September 19, 2019, reviewed by a Health Planning Specialist. The renewal license was issued with an expiration date of May 25, 2020.
Report Facts
Maximum licensed beds: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Karuga | Health Planning Specialist | Reviewed the resident contract and service agreement changes |
| Espaniola Bowen | Administrative Program Manager | Signed the renewal license letter |
Inspection Report
Renewal
Census: 19
Deficiencies: 0
Mar 18, 2019
Visit Reason
A re-licensure survey was conducted at the Assisted Living Center to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the inspection. The facility was found to be in compliance with applicable standards.
Report Facts
Census: 19
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