Inspection Reports for Bradford Village Healthcare Center
906 NORTH BOULEVARD, OK, 73034
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
42 residents
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 42
Deficiencies: 3
Nov 18, 2025
Visit Reason
A relicensure survey was conducted from November 17 through November 18, 2025, to assess compliance with state licensure requirements for the assisted living center.
Findings
The facility was found deficient in food storage, preparation, and service practices, including failure to label, date, and cover foods in the refrigerator, unclean kitchen floors with debris and grease buildup, and a can opener not cleaned between uses. These deficiencies posed potential for more than minimal harm to residents.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Foods in the refrigerators were not labeled, dated, or covered. | SS=F |
| Kitchen floors were not kept clean and free of debris. | SS=F |
| Can opener was not cleaned between use. | SS=F |
Report Facts
Facility Census: 42
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Stewart | Executive Director | Identified number of residents receiving nutrition and involved in corrective action plan |
| Lisa Calvin | Enforcement Analyst II | Signed enforcement and follow-up letters |
| Cook #1 | Interviewed regarding food labeling, cleaning practices, and kitchen sanitation |
Inspection Report
Renewal
Capacity: 177
Deficiencies: 0
Aug 27, 2025
Visit Reason
This document serves as a renewal license for the Bradford Village Healthcare Center, certifying the facility's authorization to operate as a Continuum of Care Facility.
Findings
The document certifies the renewal of the facility's license effective from 2025-08-27 through 2028-08-27, with no deficiencies or inspection findings noted in the report.
Report Facts
Licensed capacity: 177
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 3
Feb 12, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding failure to notify the physician of abnormal blood pressure readings and issues related to medication administration and care planning.
Findings
The facility failed to notify the physician when a resident's blood pressure was abnormal, failed to develop a comprehensive care plan within the required timeframe for one resident, and failed to ensure expired medications were removed and medications were administered as ordered for some residents.
Complaint Details
The complaint investigation found that the facility did not notify the physician of abnormal blood pressure readings for Resident #24, failed to develop a comprehensive care plan for Resident #170 within the required timeframe, and failed to remove expired medications and properly administer medications for several residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the physician when a resident's blood pressure was abnormal for one resident (#24) of five sampled residents reviewed for unnecessary medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan within the required timeframe for one resident (#170) of 18 sampled residents reviewed for care plans. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure expired medications were removed from circulation for three residents (#8, 46, and #56) of 10 sampled residents reviewed with controlled medications and failed to administer medications as ordered for one resident (#24) of five sampled residents reviewed for unnecessary medications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 81
Medication expiration date: Sep 22, 2024
Medication expiration date: Aug 13, 2024
Medication expiration date: Aug 27, 2024
Medication expiration date: Nov 15, 2024
Medication administration blanks: 10
Medication administration blanks: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA #1 | Certified Medication Aide | Reviewed Resident #24's blood pressures and medication administration records; stated blood pressures were abnormal and no documentation of nurse notification. |
| LPN #1 | Licensed Practical Nurse | Reviewed Resident #24's blood pressures and medication administration records; stated CMAs should have reported abnormal blood pressures and no documentation of provider notification was found. |
| DON | Director of Nursing | Reviewed Resident #24's blood pressures and medication administration records; stated no documentation of rechecking blood pressure and provider notification was found. |
| Case Manager | Case Manager | Responsible for MDS resident assessments and care plans; stated comprehensive care plan for Resident #170 was not completed within required timeframe. |
| CMA #2 | Certified Medication Aide | Observed medication cart and noted expired medications; stated facility reordered medications weekly. |
Inspection Report
Renewal
Census: 43
Deficiencies: 3
Jun 28, 2024
Visit Reason
A relicensure survey was conducted from June 26, 2024 through June 27, 2024 to assess compliance with state licensure requirements for the assisted living center.
Findings
The survey identified deficiencies related to food storage and preparation, hot water temperature exceeding allowed limits, and untimely registry screening and background checks for staff. The facility was found to have potential for more than minimal harm due to these deficiencies. A plan of correction was submitted and accepted, with a revisit scheduled to verify correction.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Foods were not labeled, dated, or secured; freezer was not maintained in good repair; staff did not use hair restraints in the kitchen; and infection control was not maintained during food preparation. | SS=E |
| Water temperatures in bathing rooms exceeded 115 degrees Fahrenheit, with readings of 136.7 and 136 degrees Fahrenheit. | SS=D |
| Registry screening and criminal background checks were not conducted in a timely manner for three staff members (CMA #1, CMA #2, Dietary Aide #1). | SS=E |
Report Facts
Facility census: 43
Dates of hire for staff with delayed background checks: CMA #1 hired 2024-02-26, CMA #2 hired 2024-03-06, Dietary Aide #1 hired 2024-05-12
Dates of registry screening and background checks completion: CMA #1 completed 2024-04-15, CMA #2 completed 2024-04-12, Dietary Aide #1 completed 2024-06-26
Hot water temperature readings: 136.7
Hot water temperature readings: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Enforcement Analyst II | Signed enforcement letters and correspondence related to the inspection and plan of correction |
| Lydia Stewart | Administrator | Facility administrator named in the inspection report and plan of correction |
Inspection Report
Census: 96
Deficiencies: 2
Nov 30, 2023
Visit Reason
The inspection was conducted to assess compliance with resident assessment accuracy and infection prevention and control program requirements, including reporting communicable diseases such as COVID-19.
Findings
The facility failed to ensure accurate resident assessments for one resident (#94) and failed to report positive COVID-19 cases for four residents (#19, 47, 48, and 146) to the Oklahoma State Department of Health (OSDH).
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure resident assessments were accurate for one (#94) of 20 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report a communicable disease to the OSDH for four (#19, 47, 48, and #146) residents reviewed for COVID-19. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 4
Resident census: 96
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 3
Nov 30, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident assessments, food safety, and infection control.
Findings
The facility was found deficient in ensuring accurate resident assessments, proper food storage and labeling, and timely reporting of communicable diseases. Specific issues included inaccurate discharge assessments, improperly sealed and dated food items with mold and spoilage, and failure to report COVID-19 cases to the state health department.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure resident assessments were accurate for one of 20 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food items were properly sealed, dated, and labeled during kitchen observations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report a communicable disease (COVID-19) to the Oklahoma State Department of Health for four residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 96
Residents affected: 4
Food items observed with issues: 9
Inspection Report
Routine
Census: 93
Deficiencies: 1
Aug 21, 2023
Visit Reason
The inspection was conducted to ensure the facility's menu met the nutritional needs of residents, was prepared in advance, followed, updated, reviewed by a dietician, and met resident needs.
Findings
The facility failed to ensure the menu was followed for one meal service observed, specifically the dessert of the day was not served to residents during lunch on 08/21/23, as confirmed by multiple resident interviews and staff statements.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the menu was followed for one meal service observed, specifically dessert was not provided as documented. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Checked meal tickets and confirmed no dessert was provided for lunch | |
| CDM | Confirmed the dessert of the day was not served to residents | |
| CNA #1 | Confirmed no desserts were served to residents during lunch |
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 12
May 31, 2023
Visit Reason
A re-licensure survey was conducted at Bradford Village Healthcare Center on May 30-31, 2023, to assess compliance with state regulations for assisted living centers.
Findings
The survey identified multiple deficiencies including issues with food storage and preparation, incomplete resident assessments, medication administration errors, and failure to report a serious fall incident timely. The facility submitted plans of correction addressing these issues, and a revisit on September 8, 2023, confirmed substantial compliance.
Severity Breakdown
Level E: 9
Level D: 1
Level B: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| The kitchen and food service equipment were not kept clean and maintained in good repair; food products were not held at proper temperatures; soiled cloths/rags were improperly stored; and there were no registering temperature indicators for the dishwasher. | Level E |
| Leftover potentially hazardous foods were held for more than 24 hours. | Level E |
| Comprehensive assessments were not completed every 12 months for two residents. | Level E |
| Admission assessments lacked required components such as signatures and dates for five residents. | Level E |
| Residents' assessments were not coordinated and signed by a registered nurse or physician for seven residents. | Level E |
| Comprehensive assessments did not include a personal interview between the resident and the person completing the form for seven residents. | Level E |
| Resident assessments were not maintained for five years from the date of assessment for two residents. | Level E |
| The facility failed to use assessment results to develop a care plan for dialysis for one resident. | Level D |
| Medications were not reviewed monthly by a registered nurse or pharmacist for seven residents. | Level B |
| Medications were not administered as ordered for two residents, including failure to administer antihypertensive medications when blood pressure readings indicated. | Level E |
| The facility failed to report a fall with serious injury to the Oklahoma State Department of Health within one business day for one resident. | Level E |
| Medication administration records were inaccurate for two residents, including failure to document administration of narcotic pain medication. | Level E |
Report Facts
Residents present: 37
Deficiencies cited: 12
Plan of correction completion date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Stewart | Administrator | Named in relation to plan of correction submissions and signature on multiple documents. |
| Lisa Calvin | Enforcement Analyst | Signed enforcement and revisit letters. |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 5
Dec 1, 2022
Visit Reason
The inspection was conducted based on complaints and allegations related to the facility's failure to maintain a clean environment, investigate abuse allegations, follow physician orders for therapy, and ensure proper medication administration.
Findings
The facility failed to provide a clean and homelike environment in one shower room, did not thoroughly investigate allegations of verbal and physical abuse for two residents, failed to ensure therapy orders were followed for one resident, and failed to ensure medications were administered as ordered for two residents. Additionally, the kitchen was not maintained clean and in good repair, and food was not stored properly.
Complaint Details
The complaint investigation focused on allegations of abuse involving CNA #2 reported by residents #12 and #184, including verbal and physical abuse, rough handling, and failure to investigate these allegations timely and thoroughly. Multiple staff and residents reported concerns, and the administrator was suspended pending investigation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide a clean homelike environment for one of five shower rooms observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure allegations related to verbal and physical abuse were reported accurately and thoroughly investigated for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have an adequate system in place to ensure physician order to receive therapy services were followed for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were administered as ordered for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the kitchen was maintained clean and in good repair, and food was stored in accordance with professional standards. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents: 85
Shower rooms: 5
Resident safe surveys: 23
Resident safe surveys - negative responses: 8
Resident safe surveys - negative responses: 2
Resident safe surveys - negative responses: 3
Pills observed on floor: 5
Pills picked up: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Named in multiple abuse allegations involving residents #12 and #184 | |
| CNA #3 | Reported abuse allegations to management multiple times | |
| LPN #1 | Licensed Practical Nurse | Observed medication administration and picking up pills from floor |
| LPN #2 | Licensed Practical Nurse | Involved in medication administration and interview about medication procedures |
| DON | Director of Nursing | Interviewed regarding abuse allegations and medication administration |
| Administrator | Administrator and Abuse Coordinator | Named in failure to investigate abuse allegations; suspended pending investigation |
| Staff Coordinator | Reported abuse allegations to administrator | |
| Regional Manager | Interviewed regarding abuse investigation and facility operations | |
| Therapy Director | Unable to locate therapy evaluation for Resident #60 | |
| DM | Dietary Manager | Interviewed regarding kitchen sanitation and food storage |
| Corp. Nurse Consult #1 | Corporate Nurse Consultant | Interviewed regarding abuse allegations and medication administration |
| CMA #1 | Certified Medication Aide | Interviewed regarding medication delivery and administration |
| ADON | Assistant Director of Nursing | Interviewed regarding medication administration observation |
Document
Census: 83
Capacity: 122
Deficiencies: 0
Jan 6, 2021
Visit Reason
The document serves as a Certificate of Need approval and investigative report for Bridges ESOP, Inc. to acquire by lease Bradford Village Healthcare Center, a 122-bed licensed nursing facility, including review of financial, staffing, and operational qualifications.
Findings
The Department found that Bridges ESOP, Inc. met all regulatory requirements including financial resources, staffing plans, and operational experience considerations. No evidence of disqualifying sanctions or substandard quality of care was found, and the Certificate of Need was approved for a 10-year lease at an annual cost of $1,062,000.
Report Facts
Licensed beds: 122
Census: 83
Annual lease cost: 1062000
Lease length (years): 10
Projected revenues: 8280602
Projected expenses: 8032191
Average monthly expenses: 669349.25
Filing fee: 3000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brett Coble | Manager | Person with controlling interest and applicant representative. |
| Jennifer Lepard | Interim Chief Operating Officer | Signed Certificate of Need approval order. |
| Astrid Chatham | Administrator | Provided statement of intent to continue employment and staffing plan. |
| Melissa Wilson | Director of Nursing | Provided statement of intent to continue employment and staffing plan. |
| Kevin Cox | Pharmacist | Provided statement of intent to continue employment and staffing plan. |
| Saqib Sheikh | Medical Director | Provided statement of intent to continue employment and staffing plan. |
| Robert Duncan | Senior Vice President, Bank of Oklahoma | Provided letter under oath confirming financial reserves and line of credit. |
Inspection Report
Renewal
Capacity: 177
Deficiencies: 0
Dec 31, 2020
Visit Reason
The document is a license renewal certificate for Bradford Village Healthcare Center, authorizing the facility to continue operating as a Continuum of Care Facility with specified bed capacities.
Findings
The document certifies the facility's license renewal with no deficiencies or findings noted.
Report Facts
Nursing Facility Beds: 122
Assisted Living Beds: 55
Adult Day Care Participants: 0
Specialized Facility Beds for Alzheimer's Residents: 0
Inspection Report
Renewal
Capacity: 177
Deficiencies: 0
Sep 16, 2019
Visit Reason
This document is a renewal license issued to BV Operations, L.L.C. for the Bradford Village Healthcare Center, certifying the facility to conduct and maintain a Continuum of Care Facility.
Findings
The license certifies that the facility meets the requirements set by the Oklahoma State Department of Health for renewal of its license to operate as a Continuum of Care Facility with a maximum capacity of 177 beds.
Report Facts
Maximum licensed beds: 177
Inspection Report
Renewal
Census: 31
Deficiencies: 1
Apr 24, 2019
Visit Reason
A State Licensure survey was conducted as a re-licensure survey at the assisted living center facility on April 24, 2019.
Findings
The facility was found deficient in coordinating and assuring the delivery of home health services for one sampled resident, resulting in isolated potential for more than minimal harm. The deficiency was related to lack of communication and coordination between the center and a third-party home health provider.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to coordinate and assure delivery of home health services for one resident, resulting in isolated potential for more than minimal harm. | SS=D |
Report Facts
Resident census: 31
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sue Davis | Enforcement Coordinator | Signed enforcement and follow-up letters |
| Kay Determan | Long Term Care Enforcement Reviewer | Signed acceptance letter of plan of correction |
| Lydia Stewart | Administrator | Named as facility administrator in initial survey and follow-up |
| Crystal Norton | Administrator | Named as facility administrator in acceptance letter of plan of correction |
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