Inspection Reports for Dorset Place-Memory Care
12401 DORSET DRIVE, OKLAHOMA CITY, OK, 73120
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
20 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 0
Date: Jun 16, 2025
Visit Reason
The complaint investigation was conducted due to allegations that the center failed to ensure residents were free from abuse, failed to provide adequate staff according to the plan of care, failed to timely assess and intervene after a fall, and failed to ensure a homelike environment.
Complaint Details
The complaint allegations included failure to ensure residents were free from abuse, inadequate staffing, failure to assess and intervene after a fall, and failure to ensure a homelike environment. The investigation found no deficient practices and no deficiencies were cited.
Findings
The investigation included observations, interviews, and record reviews. No deficient practices were found and no deficiencies were cited as a result of the complaint investigation.
Report Facts
Facility Census: 20
Sample Size: 6
Inspection Report
Renewal
Capacity: 38
Deficiencies: 0
Date: May 1, 2025
Visit Reason
This document serves as a renewal license for the assisted living center Dorset Place Memory Care, certifying the facility's authorization to operate for the period beginning May 1, 2025, through May 1, 2028.
Findings
The document certifies that OKC Dorset PL MC OPCO LLC is licensed to conduct and maintain an assisted living center with a maximum capacity of 38 beds. No deficiencies or inspection findings are stated.
Report Facts
Maximum licensed beds: 38
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
The complaint investigation was conducted due to allegations that the center failed to ensure residents were not sexually, physically, and psychosocially abused.
Complaint Details
The complaint alleged failure to ensure residents were not sexually, physically, and psychosocially abused. The investigation found no deficiencies and the complaint was not substantiated.
Findings
An unannounced on-site investigation was conducted with observations, interviews, and record reviews. No deficiencies were cited as a result of the investigation.
Report Facts
Facility Census: 25
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 7
Date: Feb 6, 2025
Visit Reason
A licensure inspection with complaint investigation was conducted due to allegations including abuse, medication administration errors, staffing issues, and environmental concerns.
Complaint Details
The complaint investigation was triggered by allegations of physical, verbal, and psychosocial abuse; ineffective pharmacy policies; lack of designated administrator and nurse; and unsafe, uncomfortable environment.
Findings
The investigation found multiple deficiencies including unsanitary kitchen conditions, lack of proper labeling of food items, incomplete resident assessments, failure to maintain medical records, lack of staff training in first aid, CPR, abuse and neglect, and failure to timely report an incident of abuse.
Deficiencies (7)
Failed to maintain a clean and sanitary kitchen; open food items not labeled with open/use by date; food stored on the floor.
Failed to ensure assessments were signed and/or coordinated by a registered nurse or physician for 3 of 8 residents.
Failed to ensure annual assessments were signed by the resident and/or resident representative for 3 of 8 residents.
Failed to maintain medical records for five years for 2 of 8 residents.
Failed to ensure staff were trained in first aid and cardiopulmonary resuscitation for 5 staff members.
Failed to report an incident of abuse to the Oklahoma State Department of Health within one department business day for 1 of 3 residents.
Failed to ensure staff were trained in abuse and neglect within 90 days of hire for 5 staff members.
Report Facts
Facility census: 28
Number of residents reviewed for assessments: 8
Number of staff reviewed for training: 5
Plan of correction completion date: Mar 24, 2025
Inspection Report
Renewal
Capacity: 38
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
This document serves as a renewal license issued to Dorset Place Senior Living, LLC, allowing the facility to continue operating as an Assisted Living Center under the name Dorset Place Memory Care.
Findings
The license certifies that the facility meets the provisions of the Oklahoma Statutes and rules adopted by the State Board of Health, authorizing it to maintain a maximum capacity of 38 beds.
Report Facts
Maximum licensed capacity: 38
Notice
Capacity: 38
Deficiencies: 0
Date: May 14, 2024
Visit Reason
This document serves as the official license certifying Dorset Place Senior Living, LLC to conduct and maintain an Assisted Living Center known as Dorset Place Memory Care.
Findings
The license confirms the facility's compliance with Oklahoma statutes and state board regulations, authorizing operation with a maximum capacity of 38 beds.
Report Facts
Maximum licensed capacity: 38
Inspection Report
Original Licensing
Capacity: 38
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
This document is an initial licensing inspection report certifying OKC MC, LLC to conduct and maintain an Assisted Living Center.
Findings
The report certifies the facility as licensed with a maximum capacity of 38 beds, effective from 2024-01-22 through 2024-07-20.
Report Facts
Maximum licensed beds: 38
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 5
Date: Oct 11, 2023
Visit Reason
A State Licensure survey with complaint investigations was conducted due to allegations of inadequate supervision to prevent falls with injury, failure to report falls and injuries, failure to admit residents requiring higher level of care, and medication administration issues.
Complaint Details
The complaint investigation included allegations of inadequate supervision to prevent falls with injury, failure to report falls with major injury and injuries of unknown origin, failure to admit residents requiring higher level of care, failure to ensure residents did not develop new/worsening pressure wounds, failure to notify representatives of changes in condition, failure to provide a comfortable homelike environment, failure to assess and intervene for residents in distress, failure to ensure assistance with ADL care, failure to report injury of unknown origin, failure to administer medications according to physician orders, failure to provide timely incontinent care, and failure to ensure dignity and reasonable access to the internet.
Findings
The investigation found multiple deficiencies including failure to complete timely and coordinated admission and comprehensive assessments, lack of required signatures on assessments, failure to ensure personal interviews for assessments, and failure to administer medication as ordered by the physician.
Deficiencies (5)
Failed to ensure an admission assessment was coordinated with required nurse signatures for one resident.
Failed to complete a comprehensive assessment within required timeframes for one resident.
Failed to ensure resident assessments were coordinated and signed by a registered nurse or physician for five residents.
Failed to ensure resident assessments included a personal interview with the resident or representative for five residents.
Failed to administer medication as ordered by the physician for one resident.
Report Facts
Residents: 21
Sampled residents: 12
Sampled residents for medication review: 3
Days medication not administered: 6
Plan of correction completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Enforcement Analyst | Signed enforcement letters related to the survey and plan of correction. |
| Joi Myeu | Divisional Director of Resident Care | Signed plan of correction documents. |
| SheKita Anderson | Administrator | Named as facility administrator in the survey documents. |
| Lori Myers | Divisional Director of Residential Care | Named as facility director in follow-up correspondence. |
Inspection Report
Renewal
Capacity: 38
Deficiencies: 0
Date: Jun 22, 2022
Visit Reason
This document is a license renewal issued to OKC 12401 Dorset BG OPCO, LLC for the operation of an Assisted Living Center named Dorset Place Memory Care.
Findings
The document certifies the facility is licensed to conduct and maintain an Assisted Living Center with a maximum capacity of 38 beds. No inspection findings or deficiencies are stated.
Report Facts
Maximum licensed beds: 38
Inspection Report
Renewal
Capacity: 38
Deficiencies: 0
Date: Mar 22, 2021
Visit Reason
This document is a license renewal issued to OKC 12401 Dorset BG OPCO, LLC for the operation of an Assisted Living Center named Dorset Place Memory Care.
Findings
The document certifies the facility is licensed to conduct and maintain an Assisted Living Center with a maximum capacity of 38 beds. It is a renewal license effective from 03/29/2021 to 03/28/2022.
Report Facts
Maximum licensed beds: 38
Inspection Report
Re-Inspection
Census: 26
Deficiencies: 10
Date: Mar 4, 2020
Visit Reason
A re-licensure survey was conducted at Dorset Place-Memory Care to assess compliance with state regulations and identify any deficiencies.
Findings
The survey identified multiple deficiencies including failure to ensure certified medication aides did not apply topical wound care medications involving decubitus treatment, failure to coordinate and sign comprehensive assessments, failure to include personal interviews in assessments, failure to develop individualized care plans for residents with open decubitus ulcers, failure to maintain accurate clinical records, and failure to obtain and review hospice/home health plans of care for residents receiving third party services.
Deficiencies (10)
Certified medication aides applied topical medication for a resident with open decubitus ulcers, which they are not authorized to do.
Registered nurse failed to coordinate and sign the comprehensive assessment for a resident.
Comprehensive assessments did not include a personal interview with the resident or representative for three residents.
Failed to develop an individualized plan of care for a resident with open decubitus ulcers.
Failed to administer prescribed topical protective cream as ordered for a resident with open decubitus ulcers.
Failed to obtain a physician's order to crush medications for a resident, resulting in unsafe medication delivery.
Administered eye drops into the wrong eye for a resident.
Failed to maintain accurate clinical records including incomplete finger stick blood sugar documentation and lack of documentation for administration of Magic Cups.
Failed to obtain and review hospice/home health plans of care and ensure coordination of third party provider services for residents receiving such services.
Failed to identify, develop, and document interventions to prevent development and worsening of decubitus ulcers for a resident, resulting in actual harm.
Report Facts
Census: 26
Deficiencies cited: 11
Wound measurements: 3
Wound measurements: 2
Medication doses: 5
Medication frequency: 4
Certification period: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lisa Wright | Administrator | Named as facility administrator in the report |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed the acceptance letter for the plan of correction |
| Katie Stagner | Long Term Care Enforcement Reviewer | Signed the acceptance letter for the plan of correction |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Oct 9, 2019
Visit Reason
A complaint survey was conducted on October 9, 2019, at Dorset Place Memory Care to investigate allegations related to resident care and elopement.
Complaint Details
Allegation #1 that the center failed to prevent elopement was substantiated. Allegation #2 that the center failed to provide care according to the resident's contract was unsubstantiated.
Findings
The investigation substantiated deficient practice related to failure to prevent elopement but did not substantiate deficient practice regarding care according to the resident's contract. The facility was required to submit a plan of correction and a follow-up investigation was planned.
Deficiencies (1)
The center failed to use the results of the residents' assessment to develop individualized care plans with interventions and goals for residents identified as an elopement risk.
Report Facts
Resident census: 31
Resident census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teena Cornett | RN CHFS IV | Signed the determination summary and follow-up action report |
Inspection Report
Renewal
Census: 27
Deficiencies: 2
Date: Apr 17, 2019
Visit Reason
A state licensure survey was conducted from April 15 through April 17, 2019, to assess compliance with assisted living center regulations and identify any deficiencies.
Findings
Deficient practice was cited related to medication administration for two residents, resulting in potential for more than minimal harm. The facility submitted a plan of correction which was accepted, and a revisit was conducted on July 23, 2019, confirming all deficiencies were cleared.
Deficiencies (2)
Failed to ensure medications were in the center and administered as ordered by the physician for 2 of 8 sampled residents, resulting in potential for more than minimal harm.
Failed to coordinate care with a third party provider to monitor and ensure delivery of services to resident #3, resulting in potential for more than minimal harm.
Report Facts
Resident census: 27
Number of sampled residents: 8
Number of residents with medication deficiencies: 2
Revisit date: Jul 23, 2019
Census at revisit: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Lisa Wright | Administrator | Named as facility administrator in relation to survey and plan of correction |
| Kay Determan | Long Term Care Enforcement Reviewer | Signed acceptance letter of plan of correction |
| Sue Davis | Enforcement Coordinator | Signed letter regarding informal dispute resolution process and enforcement |
Inspection Report
Renewal
Capacity: 38
Deficiencies: 0
Date: Mar 29, 2019
Visit Reason
This document is a renewal license issued to OKC 12401 Dorset BG OPCO, LLC for the operation of an Assisted Living Center named Dorset Place Memory Care.
Findings
The license certifies that the facility is authorized to conduct and maintain an Assisted Living Center with a maximum capacity of 38 beds, effective from 2019-03-29 to 2020-03-28.
Report Facts
Maximum licensed beds: 38
Notice
Capacity: 38
Deficiencies: 0
Date: 06 09 2020 LICENSE 110793
Visit Reason
This document serves as a license renewal for the assisted living center Dorset Place Memory Care, authorizing it to conduct and maintain operations.
Findings
The license certifies that the facility is authorized to operate as an assisted living center with a maximum capacity of 38 beds, effective from 03/29/2020 to 03/28/2021.
Report Facts
Maximum licensed beds: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lance Frye | Commissioner of Health | Signed as Commissioner of Health on the license |
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