Deficiencies (last 5 years)
Deficiencies (over 5 years)
0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
43 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 43
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The inspection was conducted as a relicensure survey of the Assisted Living Center to renew the facility's license.
Findings
The relicensure inspection conducted from March 3 to March 4, 2025, found no deficiencies cited at the facility.
Report Facts
Facility Census: 43
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as an annual survey of The Villages at Southern Hills nursing home to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
The inspection was conducted based on a complaint related to the care and treatment of residents with Moisture Associated Dermatitis (MASD), specifically focusing on whether appropriate treatment and services were provided according to standards of practice.
Complaint Details
The complaint investigation revealed that the resident's wound was open and not promptly reported by staff, with aides failing to provide timely incontinent care and the resident reporting ongoing issues with care. The Director of Nursing confirmed that appropriate incontinent care and reporting changes in condition are required parts of treatment protocols for residents with MASD.
Findings
The facility failed to ensure that a resident with MASD received necessary treatment and services consistent with standards of practice. Observations and interviews revealed that wound care was delayed and incontinent care was inconsistently provided, resulting in an open wound that was not promptly reported or treated.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals for a resident with MASD.
Report Facts
Residents with MASD: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Observed removing the resident's soiled brief and contacting the physician for wound care orders. | |
| CNA #2 | Performed incontinent care on the resident and was unsure if the wound was open. | |
| CNA #3 | Provided incontinent care and noted the wound was open but forgot to inform the nurse. | |
| LPN #3 | Spoke to CNA about the importance of timely care after resident complaint. | |
| Director of Nursing (DON) | Stated CNAs are required to report changes and provide appropriate incontinent care as part of treatment protocol. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
A relicensure survey was conducted from June 12, 2023 through June 13, 2023 to assess compliance for renewal of the assisted living center license.
Findings
No deficiencies were cited during the relicensure survey conducted at The Villages at Southern Hills.
Inspection Report
Deficiencies: 3
Date: Aug 26, 2022
Visit Reason
The inspection was conducted to evaluate compliance with pharmaceutical services and medication storage regulations at The Villages at Southern Hills nursing home.
Findings
The facility failed to ensure that a prescribed Lovenox injection was available for one resident, and medications from a discharged resident were found on the medication cart. Additionally, medication and treatment carts were observed to be unlocked and unsecured on multiple occasions, posing a risk to medication security.
Deficiencies (3)
Failed to ensure a Lovenox injection was available for one resident as prescribed.
Medications from a discharged resident were found on the medication cart and used improperly.
Medication and treatment carts were observed unlocked and unsecured multiple times.
Report Facts
Residents prescribed Lovenox: 5
Residents observed during medication pass: 12
Medication carts: 7
Treatment carts: 2
Lovenox syringes delivered on 08/16/22: 6
Lovenox syringes delivered on 08/24/22: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed preparing/administering medications and involved in medication labeling issue. |
| LPN #2 | Licensed Practical Nurse | Observed interacting with medication cart and locking it. |
| LPN #1 | Licensed Practical Nurse | Responsible for medication cart observed unlocked/unsecured. |
| CNA #1 | Certified Nursing Assistant | Observed entering wound nurse's office and identifying treatment carts. |
| DON | Director of Nursing | Interviewed regarding medication availability, storage, and security issues. |
| Wound Nurse | Responsible for treatment carts observed unlocked/unsecured. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
The inspection was conducted as a COVID-19 Special Focus Infection Control Survey and investigation of complaint #OK00057504 on August 19, 2021.
Complaint Details
The complaint alleged failure to ensure abuse-free/dignified treatment and failure to provide contracted services or ensure residents were not admitted beyond the center's care capacity. The allegation was unsubstantiated (US) after investigation.
Findings
No deficiencies were cited during the investigation. The allegation that the facility failed to ensure abuse-free/dignified treatment and proper care was unsubstantiated after review of resident interactions, documentation, and interviews.
Report Facts
Investigation dates: Investigation conducted from 2021-08-17 through 2021-08-19
Complaint number: Complaint #OK00057504
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Pritchett | RN | Signed the determination summary and follow-up action section |
Inspection Report
Routine
Census: 39
Deficiencies: 0
Date: Oct 16, 2020
Visit Reason
The inspection was a COVID-19 Special Focus Infection Control Survey conducted to determine if the facility was in compliance with implementing proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited during the COVID-19 Special Focus Survey conducted on October 16, 2020.
Report Facts
Total residents: 39
Inspection Report
Renewal
Capacity: 110
Deficiencies: 0
Date: Jan 21, 2020
Visit Reason
The document is a renewal license issued to South Lewis SH Opco, LLC for The Villages at Southern Hills, certifying the facility to conduct and maintain a Continuum of Care Facility.
Findings
This document certifies the renewal of the facility's license to operate with a maximum capacity of 110 nursing facility beds and 98 assisted living beds. No deficiencies or findings are stated in this license document.
Report Facts
Maximum Nursing Facility Beds: 110
Maximum Assisted Living Beds: 98
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