Inspection Reports for Legend at Jefferson‘s Garden
15401 N Pennsylvania Ave, Edmond, OK 73013, United States, OK, 73013
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Inspection Report
Renewal
Census: 41
Deficiencies: 4
Oct 9, 2025
Visit Reason
A state licensure survey was conducted on October 9, 2025, as part of the relicensure process for the assisted living center.
Findings
The survey identified deficiencies related to food storage and labeling, resident assessment accuracy and signatures, and laundry hot water temperature. The facility submitted an acceptable plan of correction and was found to be in substantial compliance upon a revisit on November 12, 2025.
Severity Breakdown
SS=D: 1
SS=E: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure food was stored, labeled, and dated according to center policy for 1 of 1 refrigerator observation. | SS=D |
| Failed to ensure resident assessments accurately reflected the resident status for 2 of 8 sampled residents. | SS=E |
| Failed to ensure required assessments were signed/coordinated by an RN or physician for 3 of 8 sampled residents. | SS=E |
| Failed to ensure resident's laundry was washed at an appropriate temperature for sanitization on 2 of 2 washing machines checked. | SS=F |
Report Facts
Facility census: 41
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Riley Loving | Administrator/Residence Director | Named in relation to the inspection and plan of correction |
| Lisa Calvin | Enforcement Analyst II | Author of enforcement and follow-up letters |
Inspection Report
Renewal
Capacity: 44
Deficiencies: 0
Apr 6, 2025
Visit Reason
This document serves as a license renewal for Pennsylvania ALF, LLC, an assisted living center doing business as The Legend at Jeffersons Garden, authorizing continued operation.
Findings
The license renewal certifies that the facility meets the requirements set by the Oklahoma State Department of Health and is authorized to operate with a maximum capacity of 44 beds.
Report Facts
Maximum licensed beds: 44
Inspection Report
Renewal
Census: 39
Deficiencies: 0
Apr 9, 2024
Visit Reason
A re-licensure survey was conducted on April 8 and 9, 2024 to assess compliance for renewal of the facility's license.
Findings
No deficiencies were cited during the inspection.
Report Facts
Resident census: 39
Inspection Report
Renewal
Deficiencies: 0
Feb 1, 2023
Visit Reason
A relicensure survey was conducted on January 27, 2023 and February 1, 2023 to assess compliance for renewal of the facility's license.
Findings
No deficiencies were cited during the relicensure survey conducted at the Assisted Living Center.
Inspection Report
Renewal
Capacity: 44
Deficiencies: 0
Feb 9, 2022
Visit Reason
This document is a renewal license issued to Pennsylvania ALF, LLC for The Legend at Jeffersons Garden, certifying the facility to conduct and maintain an Assisted Living Center.
Findings
The document certifies the facility's license renewal with a maximum capacity of 44 beds, effective from 04/06/2022 through 04/05/2025.
Report Facts
Maximum licensed beds: 44
Inspection Report
Renewal
Capacity: 44
Deficiencies: 0
Mar 12, 2021
Visit Reason
This document is a renewal license issued to Pennsylvania ALF, LLC for The Legend at Jeffersons Garden, certifying the facility to conduct and maintain an Assisted Living Center.
Findings
The document certifies the renewal of the facility's license with a maximum capacity of 44 beds, effective from 2021-04-06 to 2022-04-05.
Report Facts
Maximum licensed beds: 44
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Sep 10, 2019
Visit Reason
A complaint survey was conducted following allegations that the center failed to ensure medications were properly administered and residents' rights were not violated.
Findings
Deficient practices were substantiated related to medication administration and residents' rights, with potential for more than minimal harm. The facility failed to administer medications as ordered and did not provide respectful care to residents.
Complaint Details
Two allegations were substantiated: 1) improper medication administration, and 2) violation of residents' rights. The facility was required to submit a plan of correction and a follow-up investigation was planned.
Deficiencies (3)
| Description |
|---|
| Failed to ensure medications were administered as ordered, including missed doses and lack of documentation. |
| Failed to provide residents with dignity, courteousness, and respectful care, resulting in potential harm. |
| Failed to maintain organized, accurate clinical records for residents. |
Report Facts
Resident census: 39
Sample size: 11
Missed medication doses: 21
Survey dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shekita Gray | Administrator | Named in relation to plan of correction and facility administration |
| Melissa Swaim | RN | Signed the complaint investigation report |
| Sue Davis | Enforcement Coordinator | Named in enforcement and plan of correction correspondence |
| Lisa Calvin | Enforcement Reviewer/Analyst | Named in enforcement and revisit correspondence |
Inspection Report
Renewal
Capacity: 44
Deficiencies: 0
Mar 26, 2019
Visit Reason
This document is a license renewal issued to Pennsylvania ALF, LLC for The Legend at Jeffersons Garden, certifying the facility to operate as an Assisted Living Center.
Findings
The document certifies the renewal of the facility's license with a maximum capacity of 44 beds, effective from 04/06/2019 to 04/05/2020.
Report Facts
Maximum licensed beds: 44
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