Inspection Reports for
Epworth Villa Health Services

The complaint investigation substantiated a past Immediate Jeopardy related to failure to supervise a resident with exit-seeking behavior who eloped and sustained injury. The facility had a power outage that disabled door alarms, and staff were in-serviced after the incident to monitor doors more closely.

The facility failed to provide adequate supervision and interventions to prevent elopement for one resident who exited the facility and sustained injury. The door alarm system was compromised due to a power surge, and the resident's care plan did not address elopement risk despite the resident being identified as at risk.

Complaint investigation #OK00067830 was conducted from 02/26/25 to 02/27/25 based on allegations related to medication cart security, medication administration timing, food sanitation, and resident supervision in dining rooms.

The investigation found that medication carts were left unlocked while unattended and medications were left on top of treatment carts unattended. Medications were given at correct times per physician orders. Sanitary practices were upheld in the kitchen and staff were present in dining areas during meals on all floors. Additionally, nebulizer equipment was not properly rinsed, sanitized, and stored according to policy.

The facility failed to obtain informed consent for the use of bed rails for one resident and failed to ensure snacks were routinely offered to all residents as per facility policy. Observations showed snacks were not consistently passed to residents in multiple households.

The complaint investigation was initiated due to allegations that the center failed to prevent physical, verbal, or psychosocial abuse; failed to assess, monitor, intervene, and investigate injuries of unknown origin; failed to ensure adequate nutrition and prevent weight loss and pressure wounds; and failed to provide care according to service agreements and care plans. The investigation included observations, interviews, and record reviews.

The investigation found deficiencies including failure to complete a comprehensive assessment after a resident's decline following a fall, failure to report a bankruptcy to the state, and multiple medication management issues including discontinued medications remaining on medication carts and medication errors.

The facility failed to ensure comprehensive care plans included all necessary elements such as bed alarms and updated diet orders for residents. Additionally, controlled medications were not consistently signed off on the Medication Administration Record (MAR) for one resident.

The visit was complaint-related, triggered by concerns about medication administration documentation. The deficiency was substantiated based on record review and interviews.

The facility failed to ensure controlled medications were signed off on the MAR for one of six sampled residents reviewed. Specifically, Resident #57's records showed multiple instances where Percocet was removed from the medication card but not documented as administered on the MAR or PRN medication records.

The facility was found deficient in ensuring resident or representative interviews were included in comprehensive assessments, maintaining safe water temperatures in showers, providing CPR training for direct care staff, and ensuring abuse training for staff within required timeframes. A follow-up revisit confirmed all deficiencies were corrected by July 25, 2023.

Two allegations were substantiated: 1) failure to have an effective medication re-order and reconciliation program, and 2) failure to administer medications according to physician orders. The investigation included review of medication administration records, physician orders, interviews with staff and family, and observation.

The investigation substantiated deficient practices related to failure to administer medications according to physician orders and failure to reconcile medications provided by family members. Deficiencies represented potential for more than minimal harm but no actual harm was identified. A plan of correction was required and accepted.

The facility failed to follow physician orders for treatment of edema and pressure ulcers for one resident, delayed pain medication administration during wound care, and did not consistently screen employees for COVID-19 symptoms prior to shifts.

The complaint investigation was substantiated for allegations that the center failed to ensure residents were not neglected and failed to ensure medications were administered according to physician's orders.

The investigation substantiated deficient practices related to neglect and medication administration errors for two residents. Resident #1 was found on the floor after not receiving medications and safety checks for approximately 24 hours. Resident #2 had medication administration errors including failure to reconcile family-provided medications.

The survey identified deficiencies related to medication administration, specifically failure to ensure the person administering medication was identified on the medication administration record for multiple residents. The deficiencies represented potential for more than minimal harm. The facility was given an opportunity to submit a plan of correction.