Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
70 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Census: 70
Deficiencies: 1
May 8, 2025
Visit Reason
The inspection was conducted due to a past Immediate Jeopardy situation related to the facility's failure to provide supervision to protect residents with exit seeking behaviors, specifically after Resident #1 eloped and was found outside the facility.
Findings
The facility failed to provide adequate supervision and interventions to prevent elopement for Resident #1, who had exit seeking behaviors and was able to walk independently. The door alarm system was compromised due to a power surge, and Resident #1's care plan did not address elopement risk. Corrective actions included staff in-service on door alarm checks, battery replacement for door maglocks, and increased monitoring.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide supervision and interventions to prevent elopement for Resident #1 with exit seeking behaviors. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents present: 70
Elopement risk evaluation score: 14
Mental status score: 8
Time of incident: 420
Time of door observation: 1315
Time of staff text message: 1332
Time of patrol check: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Stated most residents had dementia and Resident #1 was the only ambulatory resident on household #3 |
| CMA #1 | Certified Medication Aide | Reported being in-serviced on checking door alarms and described staff supervision practices |
| CNA #1 | Certified Nursing Assistant | Reported Resident #1's refusal of care and described the elopement incident and notification process |
| Administrator | Reported alarm company visit and changes to door checking procedures | |
| DON | Director of Nursing | Described interventions for wanderers and Resident #1's care and medication changes |
Inspection Report
Routine
Census: 65
Deficiencies: 2
Oct 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident safety and care, specifically focusing on the use of bed rails and the provision of snacks to residents.
Findings
The facility failed to obtain informed consent prior to installing bed rails for one resident and failed to ensure snacks were routinely offered to all residents during evening hours, as observed in multiple households.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to obtain informed consent prior to installation of bed rails for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure snacks were offered to all residents in the facility during evening hours. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents receiving meal services: 65
Residents with bed rails: 14
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Aug 11, 2023
Visit Reason
The inspection was conducted due to a complaint or allegation regarding the facility's failure to ensure controlled medications were properly signed off on the Medication Administration Record (MAR) for accurate records.
Findings
The facility failed to ensure controlled medications were signed off on the MAR for one of six sampled residents. Specifically, Resident #57 had multiple instances where Percocet was removed from the medication card but not documented as administered on the MAR or PRN medication records. Staff interviews confirmed improper documentation practices.
Complaint Details
The visit was complaint-related, focusing on the failure to properly document administration of controlled medications. The complaint was substantiated as the facility acknowledged the findings during interviews with staff and the Director of Nursing.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure controlled medications were signed off on the MAR for Resident #57. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 67
Medication administration discrepancies: 6
Medication removal dates without documentation: 4
Inspection Report
Routine
Census: 67
Deficiencies: 3
Aug 11, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care plan development, care plan revision, and medication record accuracy for sampled residents.
Findings
The facility failed to ensure comprehensive care plans included 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.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a comprehensive care plan included a bed alarm for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update a resident's care plan to reflect current diet order. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure controlled medications were signed off on the MAR for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 67
Residents sampled for care plans: 17
Residents sampled for medication records: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 24, 2023
Visit Reason
This document is a statement of deficiencies and plan of correction for Epworth Villa Health Services following a survey completed on 2023-04-24.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 63
Deficiencies: 3
Jul 26, 2022
Visit Reason
The inspection was conducted to evaluate compliance with physician's orders for treatment, pain management, and infection prevention protocols at Epworth Villa Health Services.
Findings
The facility failed to ensure physician's orders were followed for edema and pressure ulcer treatment for one resident, failed to provide timely pain management during wound care for one resident, and did not consistently screen employees for COVID-19 symptoms prior to shifts.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Actual harm: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to follow physician's orders for treatments related to edema and pressure ulcer prevention for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pain medication timely during wound care for one resident, resulting in actual harm. | Level of Harm - Actual harm |
| Failed to have a system in place to ensure employees consistently screened for COVID-19 symptoms prior to starting their shift for five employees. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with pressure ulcers: 8
Residents with edema: 7
Residents provided wound care: 15
Resident census: 63
Days activities assistant worked without screening: 45
Days CNA #3 worked without screening: 31
Days HSKP #1 worked without screening: 38
Days HSKP #2 worked without screening: 37
Days CNA #4 worked without screening: 44
Time pain medication administered after complaint: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in pain management deficiency for not stopping wound care when Resident #28 complained of pain. |
| CNA #1 | Certified Nursing Assistant | Named in deficiencies related to edema treatment and pain management for Resident #28. |
| DON | Director of Nursing | Provided statements regarding physician orders and staff compliance. |
| RN #2 | Wound Care Nurse | Provided statements about wound care and pain medication timing for Resident #28. |
| CMA #1 | Certified Medication Aide | Administered pain medication to Resident #28. |
| Facilities Director | Provided statements about employee COVID-19 screening monitoring. | |
| Chief Nursing Officer | Provided statements about inconsistent COVID-19 screening compliance. | |
| Activities Assistant | Employee who worked multiple days without COVID-19 screening. | |
| CNA #3 | Employee who worked multiple days without COVID-19 screening. | |
| HSKP #1 | Housekeeper | Employee who worked multiple days without COVID-19 screening. |
| HSKP #2 | Housekeeper | Employee who worked multiple days without COVID-19 screening. |
| CNA #4 | Employee who worked multiple days without COVID-19 screening. |
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