Deficiencies per Year
4
3
2
1
0
Moderate
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 4
Oct 23, 2025
Visit Reason
A licensure inspection with complaint investigations was conducted due to multiple complaints alleging issues such as false billing, notification of rate increases, resident notification prior to completing a bank, medication administration, and abuse concerns.
Findings
The investigation found multiple deficiencies including failure to maintain sanitizer solution ppm levels in the dishwasher, incomplete resident assessments without required personal interviews or signatures, lack of a quality assurance committee monitoring trends and incidents, and failure to administer medications as ordered by the physician.
Complaint Details
Multiple complaints were investigated including false billing, failure to notify residents of rate increases, failure to notify residents prior to completing a bank, medication administration errors, and abuse allegations. The investigations included interviews, observations, and record reviews.
Severity Breakdown
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Sanitizer solution in the dishwasher was below recommended ppm levels for sanitization of dishware. | SS=F |
| Resident assessments did not include personal interviews or signatures from residents or their representatives for 2 of 12 sampled residents. | — |
| Internal quality assurance committee did not monitor trends and incidents for 1 of 3 sampled quarterly meetings. | — |
| Failure to administer medications as ordered by the physician for 1 of 12 sampled residents. | — |
Report Facts
Facility Census: 109
Sample Size: 12
Missed Medication Doses: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Enforcement Analyst II | Signed enforcement letters and correspondence |
| Caryl Ridgeway | Administrator | Facility administrator named in correspondence and plan of correction |
| Vice President of Quality Assurance | Provided statements regarding deficiencies and corrective actions | |
| ACMA #1 | Medication Aide | Interviewed regarding medication administration deficiencies |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Mar 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that the facility failed to protect residents from abuse.
Findings
The complaint investigation found no deficiencies cited after a thorough review including observations, interviews with residents, family, and staff, and record reviews.
Complaint Details
The complaint alleged the facility failed to protect residents from abuse. The investigation was unannounced and included interviews and observations. No deficiencies were cited, indicating the complaint was not substantiated.
Report Facts
Facility Census: 93
Complaint Number: Complaint ID OK00063202
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Clorissa Nubine | Enforcement Analyst | Author of the report and contact for questions |
Inspection Report
Renewal
Capacity: 125
Deficiencies: 0
Feb 29, 2024
Visit Reason
This document serves as a renewal license certifying that VOP Mansion at Waterford LLC is licensed to conduct and maintain an Assisted Living Center at the specified location.
Findings
The license renewal confirms compliance with the Oklahoma Statutes and State Board of Health regulations, authorizing the facility to operate with a maximum capacity of 125 beds.
Report Facts
Maximum licensed capacity: 125
Inspection Report
Original Licensing
Capacity: 125
Deficiencies: 0
Sep 1, 2023
Visit Reason
This document is the initial licensing certificate issued to VOP Mansion at Waterford LLC to conduct and maintain an Assisted Living Center.
Findings
The license certifies that the facility is authorized to operate as an Assisted Living Center with a maximum capacity of 125 beds, effective from 2023-09-01 through 2024-02-28.
Report Facts
Maximum licensed beds: 125
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Dec 20, 2022
Visit Reason
A complaint investigation was conducted due to allegations regarding infection control and medication management at The Mansion at Waterford.
Findings
The investigation found the infection control allegation unsubstantiated, but substantiated deficiencies related to medication administration, including failure to administer medications according to physician orders for two residents. A plan of correction was submitted and accepted, and a follow-up revisit confirmed all deficiencies were corrected by January 6, 2023.
Complaint Details
The complaint investigation included two allegations: failure to maintain an infection control program (unsubstantiated) and failure to have an effective medication management program (substantiated).
Deficiencies (1)
| Description |
|---|
| Failure to ensure medications were administered according to physician's orders for two residents. |
Report Facts
Residents present: 87
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherry McKee | LPN Clinical Health Facility Surveyor | Completed the infection control investigation report. |
| Theresa Williams | RN Clinical Health Facility Surveyor | Completed the medication management investigation report. |
| Katie Stagner | Enforcement Analyst | Conducted the complaint revisit and enforcement follow-up. |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 3
Dec 22, 2021
Visit Reason
Complaint investigations were conducted based on allegations including failure to ensure residents' narcotics were not misappropriated, failure to provide adequate medical care, failure to administer medications as ordered, failure to allow visitors, and failure to provide services according to residents' contracts.
Findings
The investigation found some allegations unsubstantiated, but substantiated deficiencies related to medication administration, visitation restrictions, pest control, housekeeping, and failure to discontinue medication as ordered. Deficiencies represented potential for more than minimal harm but no actual harm was identified.
Complaint Details
The complaint investigation was initiated on 12/15/2021 based on allegations of narcotics misappropriation, inadequate medical care, medication administration errors, visitation restrictions, and failure to provide contracted services. Some allegations were unsubstantiated, while others were substantiated requiring plans of correction.
Severity Breakdown
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide all services specified in the resident's current service contract for an effective pest control program and weekly housekeeping for one resident. | — |
| Failed to allow families entrance into the facility for visitation in the past three months for one resident. | — |
| Failed to discontinue a blood pressure medication as ordered by the physician in a timely manner for one resident. | SS=D |
Report Facts
Residents present: 76
Medication administration delay: 51
Dates of complaint investigation: Investigation conducted from 12/15/21 to 12/17/21 and 12/20/21 to 12/22/21.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Swaim | RN | Signed the complaint investigation report dated 12/29/2021. |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed enforcement correspondence and notices related to the complaint investigation. |
| Tempal Killman | Administrative Assistant | Signed acceptance letters for plan of correction and enforcement correspondence. |
| Sharon Flowers | Administrator | Named as facility administrator in multiple documents related to the complaint investigation. |
Inspection Report
Renewal
Capacity: 125
Deficiencies: 0
Dec 4, 2021
Visit Reason
The document is a license renewal issued to The Mansion Operations, LLC for The Mansion at Waterford Assisted Living Center.
Findings
This document certifies that the facility is licensed to conduct and maintain an assisted living center with a maximum capacity of 125 beds. It does not contain inspection findings or deficiencies.
Report Facts
Maximum licensed beds: 125
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 4
Oct 28, 2021
Visit Reason
A complaint investigation was conducted at The Mansion At Waterford related to allegations of medication administration errors, resident rights violations, service contract noncompliance, and abuse allegations.
Findings
The facility was found deficient in multiple areas including failure to provide services as per resident contracts, failure to administer medications as ordered, failure to obtain timely physician orders, failure to complete medication error reports, and failure to investigate and report abuse allegations. The revisit conducted on 2023-02-23 confirmed all deficiencies were corrected as of 2021-12-21.
Complaint Details
The complaint investigation included multiple allegations: failure to administer medications as ordered, failure to ensure resident rights to an abuse-free environment, failure to provide care according to contract, failure to address grievances, and failure to provide a safe environment. All allegations were substantiated. The investigation was conducted on 10/27/21 and 10/28/21.
Severity Breakdown
SS=E: 3
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide services according to the resident service contract including activities of daily living, housekeeping, laundry, air conditioner maintenance, and grievance process. | SS=E |
| Failure to ensure medications were administered according to physician's orders and failure to obtain timely prescriptions. | SS=E |
| Failure to maintain accurate medication administration records including medication error incident reports. | SS=D |
| Failure to investigate and report allegations of abuse. | SS=E |
Report Facts
Residents present: 90
Missed medication doses: 13
Plan of correction completion date: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachele Kemp | LPN, Facility Surveyor | Named as facility surveyor completing the complaint investigation report. |
| Jennifer Major | RN BSN MSN | Named as facility surveyor completing the complaint investigation report. |
| Lisa Calvin | Enforcement Reviewer/Analyst | Signed enforcement and follow-up letters related to the complaint investigation. |
| Tempal Killman | Administrative Assistant, Long Term Care Enforcement Division | Signed acceptance letter of plan of correction. |
| Sharon Flowers | ED/Administrator | Facility administrator during complaint revisit. |
Inspection Report
Renewal
Capacity: 125
Deficiencies: 0
Feb 23, 2021
Visit Reason
The document is a license renewal issued to The Mansion Operations, LLC to conduct and maintain an Assisted Living Center named The Mansion at Waterford.
Findings
The document certifies the renewal of the facility's license with a maximum capacity of 125 beds, issued by the Oklahoma State Department of Health.
Report Facts
Maximum licensed beds: 125
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Jun 1, 2020
Visit Reason
A COVID-19 focused infection control survey was conducted to determine if the facility was in compliance with proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to ensure safe and adequate care was provided to 15 memory care residents by allowing two direct care staff who were positive for COVID-19 to provide care to residents. The staff returned to work before the appropriate isolation period following positive COVID-19 tests.
Complaint Details
The visit was complaint-related due to concerns about COVID-19 infection control practices. The facility was found to have allowed COVID-19 positive staff to work and provide care prematurely.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility allowed two direct care staff who tested positive for COVID-19 to provide care to residents before completing the required isolation period. | SS=E |
Report Facts
Total residents: 99
Number of memory care residents affected: 15
Number of direct care staff positive for COVID-19: 4
Number of direct care staff allowed to work while positive: 2
Correction completion date: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alex Baggs | Administrator | Named as facility administrator in relation to findings and plan of correction |
| Katie Stagner | Enforcement Analyst/Coordinator/Reviewer | Named as enforcement official overseeing the inspection and enforcement process |
Inspection Report
Renewal
Capacity: 125
Deficiencies: 0
Jan 22, 2020
Visit Reason
This document is a renewal license issued to The Mansion Operations, LLC for The Mansion at Waterford Assisted Living Center, 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 125 beds, effective from 12/04/2019 to 12/03/2020.
Report Facts
Maximum licensed beds: 125
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Oct 30, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to an allegation that the facility failed to protect residents from abuse.
Findings
The allegation of resident abuse was substantiated, but no deficient practice was cited. The facility followed its abuse protocol, suspended the employee involved, and completed all necessary requirements prior to the surveyor entrance.
Complaint Details
The allegation that the facility failed to protect residents from abuse was substantiated (S). No deficient practice or violation of state regulations was found.
Report Facts
Resident census: 102
Investigation dates: Investigation conducted from 2019-10-17 to 2019-10-31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Major | RN Clinical Health Facility Surveyor | Named as a surveyor involved in the investigation |
| Melissa Swaim | RN Clinical Health Facility Surveyor | Named as a surveyor involved in the investigation |
Inspection Report
Renewal
Capacity: 125
Deficiencies: 0
Mar 13, 2019
Visit Reason
The document is a license renewal issued to The Mansion Operations, LLC for The Mansion at Waterford Assisted Living Center.
Findings
This document certifies the renewal of the facility's license to operate as an assisted living center with a maximum capacity of 125 beds.
Report Facts
Maximum licensed beds: 125
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