Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Mar 7, 2025
Visit Reason
A licensure survey with complaint investigation was conducted due to multiple allegations including failure to protect residents from retaliation, failure to follow medication administration policies, failure to notify family of change in condition, and failure to maintain a clean and safe environment.
Findings
The investigation found deficiencies including unsanitary kitchen conditions, improper storage of nebulizer equipment, failure to notify a resident's representative of radiological results timely, and inadequate staffing for safe resident transfers. Two deficiencies were cited related to the complaint investigation.
Complaint Details
The complaint investigation was initiated on 2025-03-03 based on allegations including failure to protect residents from retaliation, failure to follow medication administration policies, failure to notify family of change in condition, failure to maintain a clean and safe environment, and failure to protect residents from abuse. Two deficiencies were cited related to these allegations.
Severity Breakdown
Level 3: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain a clean and sanitary kitchen with dirty dishes left overnight, used gloves on the floor, trash on the floor, and dirty rags in the dishwashing area. | Level 3 (C 391 SS=E) |
| Failed to store nebulizer equipment properly and failed to notify a resident's representative of radiological results in a timely manner. | Level 3 (C 1505 SS=D) |
| Failed to ensure adequate staff to accommodate safe transfers for a resident requiring 2-3 persons for transfer assistance. | Level 3 (C 1507 SS=D) |
Report Facts
Facility Census: 32
Residents sampled: 9
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danna Johnson | Administrator | Named in relation to plan of correction and facility administration |
| Lisa Calvin | Enforcement Analyst II | Signed enforcement and correspondence letters |
Inspection Report
Renewal
Capacity: 43
Deficiencies: 0
Feb 24, 2025
Visit Reason
The document is a renewal license issued to Town Village Assisted Living to continue operation as an assisted living center.
Findings
The document certifies the renewal of the facility's license effective from 02/28/2025 through 02/28/2028, with no deficiencies or findings noted.
Report Facts
Maximum licensed beds: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hale | Administrative Programs Manager | Signed the renewal license letter and certification |
| Keith Reed | Commissioner of Health | Signed the license certification |
Notice
Capacity: 43
Deficiencies: 0
Sep 23, 2024
Visit Reason
This document serves as a license certifying that CHP Town Village OK Tenant Corp. is authorized to conduct and maintain an Assisted Living Center named Town Village Assisted Living.
Findings
The license is issued pursuant to Oklahoma Statutes and State Board of Health regulations, effective from 2024-09-23 to 2025-02-27, and is not transferable or assignable.
Report Facts
Licensed capacity: 43
Inspection Report
Renewal
Capacity: 43
Deficiencies: 0
Sep 23, 2024
Visit Reason
This document serves as a license renewal for the assisted living center Town Village Assisted Living, certifying the facility to conduct and maintain operations.
Findings
The license was issued pursuant to Oklahoma statutes and state board of health regulations, authorizing the facility to operate with a maximum capacity of 43 beds.
Report Facts
Maximum licensed beds: 43
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 3
Feb 28, 2024
Visit Reason
A complaint investigation was conducted due to allegations that the facility failed to prevent new or worsening pressure wounds and failed to ensure residents were provided timely incontinent care.
Findings
The investigation found deficiencies including failure to implement physician orders for daily wound care and failure to complete weekly skin assessments for residents with wounds. The facility also failed to coordinate care with third party providers for residents receiving home health and hospice services.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to prevent worsening pressure wounds and failed to provide timely incontinent care. The deficiencies represented potential for more than minimal harm but no actual harm was identified.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a physician order for daily wound care was implemented for one resident (#2). | SS=E |
| Failed to complete weekly skin assessments for residents with wound care treatments for two residents (#1 and #2). | SS=E |
| Failed to ensure coordination of care with third party providers for two residents (#1 and #2). | SS=E |
Report Facts
Facility census: 21
Deficiencies cited: 3
Plan of correction completion date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Enforcement Analyst II | Signed enforcement letters and correspondence related to the complaint investigation and plan of correction |
| Jason Sorum | Administrator/Executive Director | Named in the report as facility administrator and signatory of plan of correction |
Inspection Report
Renewal
Census: 15
Deficiencies: 16
Jun 7, 2023
Visit Reason
A relicensure survey was conducted from June 6, 2023 through June 7, 2023 to assess compliance with state licensure requirements for the assisted living facility.
Findings
The facility failed to ensure the kitchen and food service equipment were kept clean and in good repair, with multiple accumulations of residue, grease, food particles, and missing vent covers observed in the kitchen and food preparation areas. The dining director acknowledged the issues and committed to deep cleaning and establishing a cleaning schedule.
Severity Breakdown
SS=E: 16
Deficiencies (16)
| Description | Severity |
|---|---|
| Accumulation of brown residue on the outside and inside of the microwave. | SS=E |
| Accumulation of brown residue on the hand washing sink. | SS=E |
| Accumulation of brown residue on the outside of the ice machine. | SS=E |
| Accumulation of grease and brown substance on the outside of ovens, stoves, and fryers. | SS=E |
| Accumulation of grease, food particles, and brown residue on floors under fryers. | SS=E |
| Accumulation of brown and white substance on outside back and green brown substance on top outside of cold prep table. | SS=E |
| Accumulation of brown/black substance on vent cover on small freezer by cold prep table. | SS=E |
| Yellow substance on stand of commercial mixer and orange substance on mixer guard. | SS=E |
| Accumulation of brown substance on plastic storage containers in dry storage area. | SS=E |
| Accumulation of brown substance on all walls and doors in kitchen area. | SS=E |
| Two missing vent covers in dish washing area. | SS=E |
| Accumulation of black and brown substance in drains under three compartment sink in dish washing area. | SS=E |
| Trash and food particles on floor in walk-in freezer. | SS=E |
| Food particles and grease on floors in kitchen. | SS=E |
| Food particles on rug in kitchen area. | SS=E |
| Accumulation of brown substance and grease buildup on multiple ceiling tiles in kitchen area. | SS=E |
Report Facts
Residents present: 15
Deficiency count: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Sorum | Administrator | Named as facility administrator in multiple letters and reports |
| Katie Stagner | Enforcement Analyst | Signed enforcement letters related to the survey |
| Tempal Killman | Administrative Assistant II | Signed letter acknowledging acceptance of plan of correction |
| Lisa Calvin | Enforcement Analyst | Signed letter confirming offsite revisit and correction of deficiencies |
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 3
Nov 16, 2022
Visit Reason
A complaint survey was conducted due to allegations that the center failed to ensure medications were administered according to physician's orders and failed to ensure quality of care to prevent urinary tract infections.
Findings
The investigation substantiated deficient practice related to medication administration for two residents and failure to complete an annual assessment for one resident. The facility also failed to maintain complete clinical records for one resident. No actual harm was identified, and a plan of correction was accepted. A follow-up revisit confirmed all deficiencies were corrected by November 25, 2022.
Complaint Details
Complaint investigation #OK00059697 was conducted on 11/15/22 and 11/16/22. Allegation #1 regarding medication administration was substantiated; allegation #2 regarding quality of care to prevent urinary tract infections was unsubstantiated.
Severity Breakdown
Level D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure an annual assessment had been completed for one of four sampled residents. | Level D |
| Failed to ensure medications were administered according to physician orders for two of eight residents reviewed for medications. | Level D |
| Failed to maintain a complete/accurate clinical medical record for one of four sampled residents reviewed for medical records. | Level D |
Report Facts
Residents reviewed for annual assessments: 4
Residents reviewed for medications: 8
Residents reviewed for medical records: 4
Residents in facility: 17
Date of revisit: Feb 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Stagner | Enforcement Analyst | Signed enforcement letters and correspondence |
| Tempal Killman | Administrative Assistant II | Signed acceptance letter of plan of correction |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 0
Jan 22, 2020
Visit Reason
The inspection was conducted to investigate complaint #OK00054884 regarding misappropriation of residents' property at Town Village Assisted Living.
Findings
The investigation found no deficient practices or evidence of misappropriation of residents' property. Employees were observed to be kind and courteous, and residents reported no issues with missing personal property. The allegation was unsubstantiated.
Complaint Details
The allegation that the center failed to ensure residents' property was not misappropriated was unsubstantiated.
Report Facts
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marie Remer | RN, CHFS IV | Signed the determination summary and follow-up action report |
| Katie Stagner | Long Term Care Enforcement Reviewer | Author of the cover letter enclosing the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Apr 8, 2019
Visit Reason
The inspection was a complaint investigation conducted at Town Village Assisted Living on April 8, 2019, triggered by allegations of abuse and inadequate staffing related to supervision to prevent falls.
Findings
No deficiencies were cited during the investigation. Both allegations of abuse and inadequate staffing were found to be unsubstantiated after review of evidence, interviews, and records.
Complaint Details
Two allegations were investigated: 1) The center failed to provide an abuse-free environment, and 2) The center failed to have adequate staff to provide supervision to prevent falls. Both allegations were unsubstantiated (US).
Report Facts
Resident census: 23
Sample size: 6
Surveyor hours: 18.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Reviewer | Author of the cover letter for the complaint investigation report |
| Julie Edmiaston | RN, BSN, Survey Manager | Signed the investigative report and completed the report on 04/09/2019 |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 0
Feb 14, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Town Village Assisted Living related to allegations about the facility's failure to accommodate residents' needs for a bug-free environment and failure to provide care according to residents' contracts.
Findings
The investigation found no deficiencies; both allegations were unsubstantiated. No bed bugs or pests were found, and resident care was provided appropriately with no deficient practices identified.
Complaint Details
Two allegations were investigated: 1) failure to accommodate residents' needs for a bug-free environment, and 2) failure to provide care according to residents' contracts. Both allegations were unsubstantiated (US).
Report Facts
Resident census: 24
Sample size: 4
Sample size: 5
Survey hours: 4.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed cover letter for the complaint investigation report |
| Julie Edmaston | RN BSN | Completed report for pest control allegation |
| Melissa Swaim | RN | Completed report for resident contracts allegation |
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