Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
63% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
A complaint investigation was conducted due to allegations that the center failed to ensure residents were not verbally, psychosocially, sexually, or physically abused.
Complaint Details
The complaint alleged that residents were subjected to verbal, psychosocial, sexual, and physical abuse. The investigation was unannounced and included a sample of three residents. The complaint was not substantiated as no deficiencies were cited.
Findings
The investigation included observations, interviews, and record reviews. No deficiencies were cited as a result of the complaint investigation.
Report Facts
Facility Census: 95
Complaint investigations conducted: 2
Inspection Report
Renewal
Capacity: 150
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
This document is a license renewal for University Village Retirement Community, LLC, an assisted living center, authorizing continued operation.
Findings
The license renewal certifies that the facility meets the requirements to maintain its assisted living center status under Oklahoma state regulations.
Report Facts
Maximum licensed beds: 150
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey of University Village Retirement Community to assess compliance with regulatory standards across multiple areas including resident care, medication management, food services, record accuracy, arbitration agreements, and infection control.
Findings
The facility was found to have multiple deficiencies including failure to ensure privacy during catheter care, unsecured medication carts, inadequate food palatability and temperature control, unsanitary food handling practices, inaccurate medication side effect documentation, incomplete arbitration agreement language, and improper catheter tubing maintenance increasing infection risk.
Deficiencies (8)
F 0583: The facility failed to ensure privacy during urinary catheter care for one resident, with privacy curtains left open during care.
F 0761: The facility failed to ensure medications were secured in locked medication carts for two of seven carts observed.
F 0804: The facility failed to ensure meals were palatable and served at safe temperatures for three residents reviewed.
F 0812: The facility failed to ensure foods were served in a sanitary manner in two dining areas, with multiple staff not sanitizing hands or changing gloves appropriately.
F 0842: The facility failed to ensure accurate medication side effect monitoring documentation for one resident, with side effects documented but not reflected in progress notes.
F 0847: The facility failed to ensure arbitration agreements contained language allowing rescission within 30 days and stating signing was not a condition of admission for three residents.
F 0848: The facility failed to ensure arbitration agreements included language about a neutral arbitrator and convenient venue for three residents.
F 0880: The facility failed to maintain catheter tubing off the floor for two residents, risking infection.
Report Facts
Residents identified with urinary catheters: 6
Residents in facility: 72
Residents receiving nourishment from kitchen: 71
Residents eating in dining rooms: 65
Residents reviewed for unnecessary medications: 5
Residents with signed arbitration agreements: 56
Residents reviewed for arbitration agreements: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Observed providing catheter care without closing privacy curtains; stated they did not notice roommate present. | |
| LPN #1 | Observed providing catheter care without closing privacy curtains; stated they were in a rush. | |
| DON | Stated staff were to close privacy curtains during personal care and medication carts should be locked when unattended. | |
| RN #1 | Observed removing medication from unlocked cart and later locking it when questioned. | |
| RN #2 | Observed moving unlocked medication cart and removing medication. | |
| DA #1 | Observed handling ice improperly and plating food without sanitizing hands. | |
| DA #2 | Observed plating food without obtaining temperatures. | |
| DA #3 | Observed delivering meals without changing gloves or sanitizing hands. | |
| CNA #2 | Observed handing drink without sanitizing hands after repositioning resident. | |
| CNA #3 | Observed passing tray without sanitizing hands. | |
| CNA #4 | Observed delivering meals and cutting food without sanitizing hands. | |
| CNA #5 | Stated they sanitized before and after but not between passing trays. | |
| LPN #1 | Stated charge nurses monitored medication side effects and documented on TAR. | |
| Administrator | Provided statements regarding arbitration agreements and facility policies. |
Inspection Report
Census: 68
Deficiencies: 1
Date: Oct 31, 2024
Visit Reason
The inspection was conducted to evaluate compliance with bed safety policies following an incident involving a hospice supplied bed that malfunctioned and caused a resident to fall.
Findings
The facility failed to inspect a hospice supplied bed for safety prior to use by a resident, resulting in the bed breaking and the resident falling. The resident sustained a small skin tear but no serious injury was reported.
Deficiencies (1)
F 0909: The facility failed to inspect a hospice supplied bed for safety prior to use by a resident, leading to a bed malfunction and resident fall. Bed frames, mattresses, and bed rails were not checked for compatibility and size as required by facility policy.
Report Facts
Residents present: 68
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
A relicensure survey was conducted from October 2, 2023 through October 3, 2023 to assess compliance for renewal of the facility's license.
Findings
No deficiencies were cited during the inspection conducted at the Assisted Living Center.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Analyst | Signed the inspection report and communicated findings. |
Inspection Report
Routine
Census: 11
Deficiencies: 5
Date: Sep 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, wound care, respiratory care, pharmaceutical services, infection prevention and control, and resident safety.
Findings
The facility was found deficient in allowing residents to self-administer medications without physician orders, failure to notify physicians of surgical wound changes, improper administration of oxygen therapy, failure to administer blood pressure medications as ordered, and inadequate infection prevention practices including COVID-19 testing and PPE use.
Deficiencies (5)
F 0554: The facility failed to ensure a resident had a physician order to self-administer a nebulizer treatment. Resident #16 was observed self-administering without staff present or a physician order.
F 0580: The facility failed to notify the physician of a surgical wound change for resident #212. The wound had dehisced but the physician was not informed as required.
F 0695: The facility failed to administer oxygen according to physician orders for resident #213. Oxygen was set above ordered level and resident was observed without portable oxygen when required.
F 0755: The facility failed to ensure blood pressure medications were administered as ordered for resident #12. Medications were held despite vital signs being within parameters.
F 0880: The facility failed to implement infection prevention and control measures including COVID-19 staff testing during outbreak, proper PPE use, and hand hygiene during wound care.
Report Facts
Residents receiving respiratory treatments: 11
Residents with blood pressure medications with parameters: 31
Medication hold occurrences: 4
Medication hold occurrences: 4
Medication hold occurrences: 7
Medication hold occurrences: 10
Residents on COVID isolation precautions: 6
Residents receiving wound care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Observed shutting off nebulizer treatment and interviewed about protocol for nebulizer administration | |
| RN #2 | Interviewed about nebulizer treatment protocol, wound care, oxygen administration, and medication administration | |
| DON | Interviewed regarding wound notification, oxygen administration, medication administration, PPE use, and infection control policies | |
| IP | Interviewed regarding COVID-19 testing and outbreak status | |
| CNA #1 | Observed in isolation room not wearing required PPE |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 4, 2022
Visit Reason
The inspection was conducted as a complaint investigation at the Assisted Living facility following allegations related to medication administration, timely response to call lights, and treatment of residents with dignity and respect.
Complaint Details
The complaint investigation included three allegations: failure to administer medications as per physician's orders, failure to answer call lights timely, and failure to treat residents with dignity and respect. All allegations were unsubstantiated (US).
Findings
The investigation found all three allegations to be unsubstantiated with no deficiencies cited. Residents were observed to be well cared for, and staff provided timely assistance and treated residents with dignity and respect.
Report Facts
Complaint investigation dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Stagner | Long Term Care Enforcement Reviewer | Signed the cover letter for the complaint investigation report |
| B. Garrison | R.N. | Signed the determination summary and follow-up action section |
Inspection Report
Renewal
Capacity: 150
Deficiencies: 0
Date: Jan 29, 2022
Visit Reason
This document is a renewal license issued to University Village Retirement Community, 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 150 beds, effective from 2022-01-29 through 2025-01-28.
Report Facts
Maximum licensed beds: 150
Inspection Report
Routine
Deficiencies: 1
Date: Oct 8, 2021
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on wound care practices.
Findings
The facility failed to implement correct hand hygiene infection control for one of five sampled residents reviewed for wound care. Licensed practical nurses were observed not performing hand hygiene appropriately during wound care.
Deficiencies (1)
F 0880: The facility failed to implement correct hand hygiene infection control for resident #35 during wound care. The nurse did not perform hand hygiene when changing gloves before applying ointment.
Report Facts
Residents with wounds: 14
Residents sampled for wound care review: 5
Resident #35 wound care observation date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Observed performing wound care and failing to perform hand hygiene correctly. | |
| Licensed Practical Nurse (LPN) #2 | Observed performing wound care. |
Inspection Report
Renewal
Capacity: 150
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
This document serves as a license renewal for University Village Retirement Community, LLC to conduct and maintain an Assisted Living Center.
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 150 beds.
Report Facts
Maximum licensed beds: 150
Inspection Report
Renewal
Capacity: 150
Deficiencies: 0
Date: Feb 25, 2020
Visit Reason
This document is a license renewal for University Village Retirement Community, LLC, an assisted living center, issued by the Oklahoma State Department of Health.
Findings
The document certifies that the facility is licensed to conduct and maintain an assisted living center with a maximum capacity of 150 beds. It serves as official confirmation of license renewal.
Report Facts
Maximum licensed beds: 150
Inspection Report
Renewal
Census: 102
Deficiencies: 0
Date: May 16, 2019
Visit Reason
A re-licensure survey was conducted on May 15 and May 16, 2019, at University Village Retirement Community to assess compliance for renewal of the assisted living center license.
Findings
No deficient practices or deficiencies were cited during the inspection.
Report Facts
Resident census: 102
Inspection Report
Renewal
Capacity: 150
Deficiencies: 0
Date: Jan 29, 2019
Visit Reason
The document is a license renewal issued to University Village Retirement Community, LLC to conduct and maintain an Assisted Living Center.
Findings
This document certifies the renewal of the facility's license to operate as an Assisted Living Center, effective from January 29, 2019, through January 28, 2020.
Report Facts
Maximum licensed beds: 150
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