Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
30 residents
Based on a October 2024 inspection.
Census over time
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Date: Jul 20, 2025
Visit Reason
This document serves as a renewal license certifying that PF Yukon ALF Ops, LLC is licensed to conduct and maintain an Assisted Living Center named Victorian Estates.
Findings
The license is issued pursuant to Oklahoma statutes and state board regulations, authorizing the facility to operate with a maximum capacity of 70 beds. No deficiencies or findings are noted in this document.
Report Facts
Maximum licensed capacity: 70
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
A complaint investigation was conducted due to an allegation that the center failed to ensure pets were vaccinated and/or health was maintained, and pets were cared for in a manner to prevent an unsanitary environment according to contracted services.
Complaint Details
The complaint alleged failure to ensure pets were vaccinated and cared for to prevent an unsanitary environment. The investigation found no deficiencies.
Findings
The investigation included observations, interviews, and record reviews related to pet care and environmental concerns. No deficiencies were cited as a result of the complaint investigation.
Report Facts
Facility Census: 30
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
The inspection was conducted as a licensure standard survey combined with a complaint investigation triggered by allegations regarding notification and involvement of residents' representatives and hospice in treatment decisions, coordination of care with hospice, adherence to advance directives, and notification of rate increases.
Complaint Details
The complaint investigation addressed three allegations: failure to notify/involve residents' representatives and hospice in hospital transfers; failure to coordinate care with hospice and follow advance directives; and failure to notify residents/representatives of rate increases. The investigation was unannounced, included a sample of eight residents, and involved observations, interviews, and record reviews. No deficiencies were substantiated.
Findings
The investigation found no deficiencies. Observations, interviews, and record reviews indicated that the facility complied with relevant standards, and no violations were cited.
Report Facts
Facility Census: 30
Complaint Investigation Sample Size: 8
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Date: May 25, 2023
Visit Reason
A state licensure survey with a complaint investigation was conducted due to allegations including failure to implement an infection control program for Covid-19, neglect of residents, and unqualified staff performing job duties.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to have and/or implement an infection control program for Covid-19, failed to ensure residents were not neglected, and failed to ensure staff were qualified and/or licensed to perform their job duties.
Findings
The investigation found deficiencies including failure to ensure dietary staff had required food service training, incomplete annual comprehensive assessments for residents, lack of RN or physician signatures on assessments, failure to conduct personal interviews for assessments, improper transcription of physician orders by unqualified staff, and failure to identify close contacts for residents positive for Covid-19.
Deficiencies (6)
Two of two sampled dietary staff responsible for food preparation had not attended a food service training program approved by the Oklahoma State Department of Health.
Failed to complete an annual comprehensive assessment for four of eight residents sampled.
Failed to ensure a comprehensive assessment was coordinated and signed by a registered nurse or physician for one of eight residents sampled.
Failed to conduct a personal interview for one of eight residents sampled for comprehensive assessments.
Failed to ensure physician orders were transcribed by a licensed nurse for one of ten sampled residents reviewed for medications.
Failed to follow the center's policy and identify close contacts/staff for residents positive for COVID-19 for three of three residents sampled for infection control.
Report Facts
Residents identified: 35
Residents sampled for assessments: 8
Residents sampled for medication review: 10
Residents positive for COVID-19: 3
Date of inspection: May 25, 2023
Date of plan of correction completion: Jul 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Edmiaston | RN, BSN | Signed the investigative report dated 05/26/2023 |
| Brandy Ratcliff | Regional Director of Operations / Administrator | Signed plan of correction documents and correspondence |
| Lisa Calvin | Enforcement Analyst | Signed enforcement correspondence |
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
This document is a renewal license issued to PF Yukon ALF Ops, LLC to conduct and maintain an Assisted Living Center named Victorian Estates.
Findings
The license certifies that the facility meets the requirements set by the Oklahoma State Department of Health for renewal of its Assisted Living Center license.
Report Facts
Maximum licensed beds: 70
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Date: Mar 21, 2022
Visit Reason
This document is a license issued to PF Yukon ALF Ops, LLC to conduct and maintain an Assisted Living Center, indicating a renewal or initial licensing action.
Findings
The document certifies the licensing of the facility named Victorian Estates with a maximum capacity of 70 beds. It confirms the license type as Extended Initial with effective and expiration dates.
Report Facts
Maximum licensed beds: 70
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Date: Feb 1, 2022
Visit Reason
A complaint investigation was conducted at Victorian Estates Assisted Living Center based on allegations of deficient practices related to staffing, medication administration, and infection control.
Complaint Details
Complaint investigation was substantiated for failure to provide adequate staff, failure to maintain assessments, and failure to ensure medications were administered as prescribed. One allegation related to infection control was unsubstantiated.
Findings
The investigation substantiated deficiencies including failure to provide adequate staff, failure to maintain assessments for a discharged resident, and failure to ensure medications were administered as prescribed for one resident. One allegation related to infection control was unsubstantiated. The facility submitted an acceptable plan of correction and a revisit confirmed all deficiencies were corrected by March 25, 2022.
Deficiencies (6)
Failed to maintain assessments (clinical record) for one of three sampled closed records.
Failed to ensure medications were administered as prescribed for one of three sampled residents with medication assistance.
Failed to provide adequate staff to meet the needs of residents.
Failed to ensure residents received medications as prescribed.
Failed to ensure staff were qualified to perform assigned tasks and failed to ensure proper administration of medications.
Failed to ensure staff followed proper infection control procedures.
Report Facts
Residents present: 35
Medication doses missed: 35
Plan of Correction completion date: Mar 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Edmiaston | RN, BSN | Signed the investigative report documenting findings and substantiations. |
| Katie Stagner | Enforcement Reviewer/Analyst | Signed enforcement correspondence and complaint revisit letter. |
| Marcie Musick | Administrator | Facility administrator during the complaint investigation and plan of correction submission. |
Inspection Report
Original Licensing
Capacity: 70
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
This document is an initial licensing certificate issued to PF Yukon ALF Ops, LLC for the operation of an Assisted Living Center named Victorian Estates.
Findings
The document certifies that the facility is licensed to conduct and maintain an Assisted Living Center with a maximum capacity of 70 beds, effective from 09/22/2021 to 03/21/2022.
Report Facts
Maximum licensed capacity: 70
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Date: Feb 22, 2021
Visit Reason
This document is a license renewal certificate for Yukon ALF OPCO, LLC, doing business as Victorian Estates, an Assisted Living Center, indicating the renewal of the facility's license.
Findings
The document certifies that the facility is licensed to conduct and maintain an Assisted Living Center with a maximum capacity of 70 beds. It is issued pursuant to Oklahoma statutes and rules by the State Board of Health.
Report Facts
Maximum licensed beds: 70
Inspection Report
Routine
Census: 31
Deficiencies: 0
Date: Aug 14, 2020
Visit Reason
The inspection was a COVID-19 Special Focus Infection Control Survey 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
No deficiencies were cited during the COVID-19 Special Focus Survey conducted on August 14, 2020.
Report Facts
Total residents: 31
Inspection Report
Renewal
Census: 30
Deficiencies: 4
Date: Dec 10, 2019
Visit Reason
A state licensure survey was conducted on December 9 and 10, 2019, as part of a relicensure process for Victorian Estates assisted living center.
Findings
Deficiencies were found related to medication administration, specifically failure to document insulin injection sites and administration times for sampled residents. The deficiencies represented potential for more than minimal harm. The facility submitted an acceptable plan of correction with a target compliance date of January 7, 2020. A follow-up visit on January 9, 2020, verified correction of the deficiencies.
Deficiencies (4)
Failure to ensure insulin injection sites were documented for 2 sampled residents administered insulin by home health nurses.
Failure to document insulin administration times for 2 sampled residents receiving insulin injections by home health nurses.
Failure to maintain an accurate written record of medications administered including identity and signature of person administering, medication within one hour of scheduled time, and medication error incident reports.
Failure to coordinate care and services between the center and third party providers for finger stick blood sugars and insulin administration.
Report Facts
Resident census: 30
Resident census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Latasha Winship | Administrator | Named as facility administrator in relation to survey and plan of correction |
| Sue Davis | Enforcement Coordinator / Long Term Care Enforcement Reviewer | Signed enforcement and follow-up letters related to the survey |
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Date: Apr 3, 2019
Visit Reason
This document is a license renewal issued to Yukon ALF OPCO, LLC for the operation of an Assisted Living Center named Victorian Estates.
Findings
The document certifies the facility's license to conduct and maintain an Assisted Living Center with a maximum capacity of 70 beds. It does not include inspection findings or deficiencies.
Report Facts
Maximum licensed beds: 70
Notice
Capacity: 70
Deficiencies: 0
Date: 04 07 2020 LICENSE 111410
Visit Reason
This document serves as a license renewal for the assisted living center operated by Yukon ALF OPCO, LLC, confirming authorization to conduct and maintain the facility.
Findings
The document certifies the facility's license renewal with an effective date of 03/30/2020 and an expiration date of 03/29/2021, with no inspection findings or deficiencies noted.
Report Facts
Maximum licensed beds: 70
Notice
Capacity: 70
Deficiencies: 0
Date: 04 27 2020 LICENSE 105045
Visit Reason
This document serves as a license renewal for the assisted living center Victorian Estates, certifying that Yukon ALF OPCO, LLC is licensed to conduct and maintain the facility.
Findings
The document certifies the renewal of the assisted living center license effective from 03/30/2020 through 03/29/2021, with no deficiencies or inspection findings reported.
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