Inspection Reports for Brookdale Edmond Danforth
116 W Danforth Rd, Edmond, OK 73003, OK, 73003
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35 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: 35
Deficiencies: 0
Date: Nov 4, 2025
Visit Reason
A relicensure survey was conducted on 10/28/25, 10/30/25, and 11/04/25 to assess compliance for license renewal at the Assisted Living Center.
Findings
No deficiencies were cited during the relicensure survey conducted on the specified dates.
Report Facts
Facility Census: 35
Inspection Report
Renewal
Capacity: 43
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
This document is a license renewal issued to BKD Sterling House of Edmond, LLC for their Assisted Living Center, Brookdale Edmond Danforth.
Findings
The license certifies that the facility is authorized to conduct and maintain an Assisted Living Center with a maximum capacity of 43 beds. The license is effective from 09/22/2025 through 09/22/2028.
Report Facts
Maximum licensed beds: 43
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations that the center failed to provide adequate supervision to prevent elopement and failed to ensure a working call system for residents to communicate their needs to nursing staff.
Complaint Details
Two complaints were investigated: one alleging failure to provide adequate supervision to prevent elopement, and another alleging failure to ensure a working call system for residents. Both investigations found no deficiencies and no substantiated violations.
Findings
Two complaint investigations were conducted on December 19, 2024, involving allegations of inadequate supervision to prevent elopement and failure to maintain a working call system. No deficiencies were cited following the investigations, and the facility was found to have no violations related to fire safety or exit doors.
Report Facts
Facility Census: 29
Sample Size: 4
Investigation Start Time: 843
Fire Marshall Inspection Dates: 100224
Fire Marshall Recheck Date: 121024
Staff Response Time: 2
Expected Staff Response Time: 15
Inspection Report
Renewal
Census: 61
Deficiencies: 1
Date: Jun 25, 2024
Visit Reason
A state licensure survey was conducted as part of the relicensure process for the assisted living center.
Findings
The facility was found to have deficiencies related to failure to coordinate care provided by a third-party hospice provider for one of four sampled residents. The facility failed to ensure that interim orders were reviewed and incorporated into the resident's medication regimen and that third-party documentation was reviewed.
Deficiencies (1)
Failed to coordinate care provided by third-party hospice provider for one of four sampled residents, including failure to review interim orders and third-party documentation.
Report Facts
Facility census: 61
Residents receiving third-party services: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Enforcement Analyst II | Signed enforcement and follow-up letters |
| Lisa Dimonico | Administrator | Facility administrator named in correspondence and plan of correction |
| RN #1 | Registered Nurse | Acknowledged responsibility for coordinating care with third-party providers |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2023
Visit Reason
The inspection was conducted in conjunction with a complaint investigation regarding allegations that the facility failed to ensure the right to self-administer medications, accurate assessments upon admission, adequate staffing, and timely assistance with activities of daily living.
Complaint Details
The complaint investigation was related to allegations about medication self-administration, assessment accuracy, staffing adequacy, and assistance with daily living. The complaint was unsubstantiated as no deficiencies were cited.
Findings
The investigation found no deficiencies; residents received physician-ordered medications and assistance with daily living activities, and staff provided care as required. The resident had not passed the self-medication assessment, but no deficient practice was cited.
Report Facts
Complaint Number: Complaint #OK00060671 referenced in the investigation
Investigation Dates: Investigation conducted on 2023-05-22 and 2023-05-23
Date of self-medication assessment: Resident did not pass self-medication assessment on 2023-05-12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Franklin Calvin | Signed the investigative report | |
| Katie Stagner | Long Term Care Enforcement Analyst | Author of the cover letter and report |
Inspection Report
Renewal
Capacity: 43
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
This document is a renewal license issued to BKD Sterling House of Edmond, LLC to conduct and maintain an Assisted Living Center.
Findings
The license certifies that the facility meets the provisions of the Oklahoma Statutes and State Board of Health regulations for operation as an Assisted Living Center.
Report Facts
Maximum licensed beds: 43
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
A complaint investigation was conducted at the Assisted Living facility regarding an allegation that the facility failed to assess, monitor, and intervene to prevent resident illness or injury.
Complaint Details
The allegation that the facility failed to assess, monitor, and intervene to prevent resident illness or injury was unsubstantiated (US). No deficiencies were cited.
Findings
The investigation found no deficient practice; the allegation was unsubstantiated. Staff were observed assisting residents according to their personal service plans, and residents at risk for falls had interventions in place.
Report Facts
Investigation Dates: 2
Sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Cooper | Health Facility Surveyor | Signed the report and conducted the investigation |
| Lisa Calvin | Long Term Care Enforcement Reviewer | Author of the cover letter accompanying the report |
Inspection Report
Renewal
Capacity: 43
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
This document is a license renewal issued to BKD Sterling House of Edmond, LLC to conduct and maintain an Assisted Living Center.
Findings
The license renewal certifies that the facility is authorized to operate as an Assisted Living Center with a maximum capacity of 43 beds, effective from 09/22/2021 to 09/21/2022.
Report Facts
Maximum licensed beds: 43
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 6
Date: Feb 4, 2020
Visit Reason
A complaint investigation was conducted at the Assisted Living Center to investigate allegations related to medication administration and pest control.
Complaint Details
The complaint investigation was unsubstantiated for allegations that the center failed to ensure medications were properly administered and failed to have an effective pest control program.
Findings
The complaint investigation found that the allegations of improper medication administration and ineffective pest control were unsubstantiated. However, a re-licensure survey conducted on the same dates identified deficiencies related to medication administration, nurse supervision, medication review, documentation, and coordination of care.
Deficiencies (6)
Failed to ensure oral metered dose inhalers were administered by certified medication aides with advanced training.
Failed to ensure registered nurse supervision for residents self-administering medications.
Failed to ensure the registered nurse reviewed residents' medications monthly.
Failed to have a physician's order for two medications found in residents' rooms.
Failed to ensure accurate documentation for medication administration.
Failed to coordinate care with third party providers for a resident with warfarin and PT/INR lab orders.
Report Facts
Resident census: 30
Sample size: 8
Sample size: 2
Sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Dimonico | Administrator | Named as facility administrator in multiple documents |
| Mary Cooper | RN | Signed the investigative report dated 02/06/2020 |
| Katie Stagner | Long Term Care Enforcement Reviewer | Signed acceptance letter for plan of correction on 09/03/2020 |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed letter confirming correction of deficiencies on 11/16/2020 |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Sep 25, 2019
Visit Reason
An abbreviated complaint survey was conducted from September 23 through September 25, 2019, to investigate complaint #OK00054380 regarding resident care and abuse policy implementation.
Complaint Details
Complaint #OK00054380 was substantiated for allegations that the center failed to provide care according to plans and contracts and failed to implement their abuse policy. The investigation included interviews, observations, and record reviews. Deficient practices were found related to neglect of a cognitively impaired resident who suffered a fractured femur and failure to follow abuse policy.
Findings
Deficient practices were substantiated related to failure to provide care according to plans and contracts and failure to implement the abuse policy. The facility neglected a cognitively impaired resident resulting in a fractured femur and failed to follow their abuse policy during the investigation.
Deficiencies (2)
Failure to ensure residents were provided care according to care plans and contracts, resulting in abuse/neglect of a resident with a fractured femur.
Failure to have and/or implement the abuse policy during investigation of injury of unknown origin.
Report Facts
Resident census: 36
Survey dates: 2019-09-23 to 2019-09-25
Revisit date: Feb 4, 2020
Revisit census: 30
Plan of correction completion date: Nov 23, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Dimonico | Administrator | Named in relation to plan of correction and investigation |
| Sue Davis | Enforcement Coordinator | Signed enforcement and correspondence letters |
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed acceptance letter of plan of correction |
| Teena Cornett | RN CHFS IV | Signed investigative report |
| Lisa McAlister | Manager of Survey and Compliance | Signed amended statement of deficiencies |
Inspection Report
Renewal
Capacity: 43
Deficiencies: 0
Date: Sep 22, 2019
Visit Reason
The document is a license renewal for the assisted living center BKD Sterling House of Edmond, LLC, doing business as Brookdale Edmond Danforth.
Findings
The license certifies that the facility is authorized to conduct and maintain an assisted living center with a maximum capacity of 43 beds, effective from 2019-09-22 to 2020-09-21.
Report Facts
Maximum licensed beds: 43
Inspection Report
Renewal
Census: 37
Deficiencies: 0
Date: Mar 21, 2019
Visit Reason
A re-licensure survey was conducted from March 20 through March 21, 2019, to assess compliance for license renewal at the assisted living center.
Findings
No deficiencies were cited during the inspection. The resident census was 37 at the time of the survey.
Report Facts
Resident census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kay Determan | Long Term Care Enforcement Reviewer | Signed the cover letter of the inspection report |
Inspection Report
Renewal
Capacity: 43
Deficiencies: 0
Date: Feb 8, 2019
Visit Reason
This document serves as a renewal license certifying that Brookdale Senior Living Communities, Inc. is licensed to conduct and maintain an Assisted Living Center at the specified location.
Findings
The license is issued pursuant to Oklahoma statutes and state board of health regulations, authorizing operation of the facility with a maximum capacity of 43 beds.
Report Facts
Maximum licensed beds: 43
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