Inspection Reports for Village on the Park Oklahoma City

OK

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Inspection Report Complaint Investigation Census: 40 Deficiencies: 1 Nov 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on allegations that the center failed to ensure staff followed pharmacy procedures for accurate reconciliation and accounting for controlled medications, and failed to ensure a safe, clean, comfortable, and homelike environment, including serving palatable food.
Findings
The investigation included observations, interviews, and record reviews. Residents were generally clean and well cared for, medication administration was observed, and medication records were reviewed. Deficiencies were cited related to medication administration errors, specifically an incorrect dose given to one resident. The facility was otherwise observed to be clean, odor free, and homelike with no safety issues noted.
Complaint Details
The complaint investigation involved two complaint numbers (#OK00067006 and #OK00073971) with allegations regarding medication administration errors and environmental concerns including food palatability. The investigation was unannounced and included a sample of 8 residents. The findings included medication administration errors and no safety or environmental concerns.
Deficiencies (1)
Description
Failed to ensure the correct dose of medication was administered for one resident (#8) during medication administration.
Report Facts
Residents sampled: 8 Facility census: 40
Employees Mentioned
NameTitleContext
Advanced Certified Medication Aide (ACMA)Observed administering incorrect medication dose to resident #8
Karen ProctorAdministratorNamed in correspondence related to inspection and plan of correction
Tempal KillmanEnforcement AnalystSigned enforcement and follow-up letters
Inspection Report Renewal Capacity: 64 Deficiencies: 0 Nov 23, 2024
Visit Reason
This document serves as a renewal license for the assisted living center Village on the Park- Oklahoma City, certifying the facility's authorization to operate for the period beginning 2024-11-23 through 2027-11-23.
Findings
The document certifies that Cardinal Bay, Inc. is licensed to conduct and maintain an assisted living center with a maximum capacity of 64 beds. It confirms compliance with Oklahoma State Department of Health regulations for license renewal.
Report Facts
Maximum licensed capacity: 64
Inspection Report Complaint Investigation Census: 36 Deficiencies: 0 Jan 8, 2024
Visit Reason
A complaint investigation was conducted due to an allegation that the facility failed to protect residents from sexual abuse.
Findings
The investigation found no deficiencies. Residents and staff interviews, observations, and record reviews indicated that residents felt safe and no abuse was identified.
Complaint Details
The complaint alleged failure to protect residents from sexual abuse. The investigation was unannounced and included interviews, observations, and record reviews. The complaint was not substantiated as no deficiencies were cited.
Report Facts
Sample residents selected: 3 Facility census: 36
Inspection Report Complaint Investigation Census: 18 Deficiencies: 2 May 11, 2023
Visit Reason
A complaint investigation was conducted based on allegations that the center failed to notify residents' representatives of changes in condition and failed to ensure certified, adequately trained staff were providing care for dependent residents.
Findings
The investigation found no deficient practice related to the complaint allegations. However, the licensure survey identified deficiencies including failure to provide safety checks every two hours for three residents, and failure to submit an incident report related to an elopement. The facility was found to be in substantial compliance upon revisit.
Complaint Details
Complaint investigation #OK00060226 was initiated on 05/09/2023 based on allegations of failure to notify residents' representatives of changes in condition and failure to ensure certified, adequately trained staff were providing care. The investigation included observations, interviews, and record reviews. No deficient practice was cited related to the complaint.
Severity Breakdown
SS=E: 1 SS=D: 1
Deficiencies (2)
DescriptionSeverity
Failed to provide safety checks every two hours per the service plan for three residents (#5, #6, and #8).SS=E
Failed to submit an incident report to the Oklahoma State Department of Health related to an elopement for one resident (#6).SS=D
Report Facts
Residents in Memory Care Unit: 18 Safety check opportunities missed: 129 Safety check opportunities missed: 135 Safety check opportunities missed: 142 Investigation dates: 3
Employees Mentioned
NameTitleContext
Alisha ConleyClinical Health Facility SurveyorSigned complaint investigation report
Katie StagnerEnforcement AnalystSigned enforcement process letters
Tempal KillmanAdministrative Assistant IISigned letter accepting plan of correction
Lisa CalvinEnforcement AnalystSigned letter confirming correction of deficiencies
Inspection Report Complaint Investigation Census: 20 Deficiencies: 1 Dec 21, 2022
Visit Reason
A complaint investigation was conducted due to an allegation that the center failed to ensure residents were not neglected.
Findings
The investigation substantiated deficient practice related to neglect, specifically failure to provide required safety checks every two hours for three residents. Documentation showed numerous missed safety checks and resident interviews indicated neglect concerns.
Complaint Details
The complaint allegation that the center failed to ensure residents were not neglected was substantiated. The facility was required to submit a plan of correction and a follow-up investigation was planned.
Severity Breakdown
SS=E: 1
Deficiencies (1)
DescriptionSeverity
Failure to provide safety checks every two hours per the service plan for three residents reviewed for neglect.SS=E
Report Facts
Residents in Memory Care Unit: 20 Missed safety check opportunities for Resident #1: 151 Missed safety check days for Resident #2: 6 Missed safety check opportunities for Resident #3: 217
Employees Mentioned
NameTitleContext
Andrew ConleyClinical Health Facility SurveyorSigned the investigative report dated 2022-12-22.
Katie StagnerEnforcement AnalystSigned enforcement correspondence and follow-up letters.
Tempal KillmanAdministrative Assistant IISigned letter accepting plan of correction.
Inspection Report Complaint Investigation Deficiencies: 0 May 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation at the Assisted Living facility.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint investigation conducted; no deficiencies were cited.
Employees Mentioned
NameTitleContext
Katie StagnerLong Term Care Enforcement ReviewerSigned the complaint investigation report.
Inspection Report Renewal Capacity: 64 Deficiencies: 0 Feb 9, 2022
Visit Reason
This document is a renewal license issued to Cardinal Bay, Inc. for the Assisted Living Center Village on the Park in Oklahoma City, certifying the facility to continue operation.
Findings
The document certifies the facility's license renewal with no deficiencies or inspection findings noted.
Report Facts
Maximum licensed beds: 64
Inspection Report Complaint Investigation Deficiencies: 3 May 25, 2021
Visit Reason
A complaint survey was conducted at Village on The Park - Oklahoma City on May 24-25, 2021, triggered by multiple complaints regarding staffing, medical care, and resident safety.
Findings
The investigation found deficiencies including failure to disclose one-person staffing and emergent situation plans, inadequate staffing levels, failure to obtain signed physician orders for medications, failure to notify Power of Attorney about medication changes, and incomplete clinical documentation regarding resident behaviors, falls, and transfers.
Complaint Details
The complaint investigation was substantiated for failure to provide sufficient staff to meet residents' needs and failure to ensure residents received adequate and appropriate medical care. One allegation of neglect was unsubstantiated.
Severity Breakdown
SS=E: 3
Deficiencies (3)
DescriptionSeverity
Failure to disclose one-person staffing and have an approved plan for emergent situations, with potential for harm to residents.SS=E
Failure to ensure residents received adequate and appropriate medical care, including lack of signed physician order for Hydroxychloroquine and failure to notify Power of Attorney.SS=E
Failure to maintain an organized, accurate clinical record for residents, including lack of documentation of medication orders, resident behaviors, falls, and transfers.SS=E
Report Facts
Investigation dates: 2021-05-24 to 2021-05-25 Total residents: 27 Plan of correction completion date: Aug 1, 2021
Employees Mentioned
NameTitleContext
Julie EdmiastonRN, BSNSigned the complaint investigation reports dated 05/26/2021
Karen ProctorAdministratorFacility administrator named in correspondence and plan of correction
Tempal KillmanAdministrative Assistant, Long Term Care EnforcementSigned letters regarding plan of correction acceptance and requests
Inspection Report Renewal Capacity: 64 Deficiencies: 0 Jan 19, 2021
Visit Reason
The document is a license renewal for Cardinal Bay, Inc. operating an Assisted Living Center named Village on the Park- Oklahoma City.
Findings
The document certifies the facility's license renewal and compliance with Oklahoma State Board of Health regulations. No deficiencies or findings are noted.
Report Facts
Maximum licensed beds: 64
Inspection Report Routine Census: 26 Deficiencies: 0 Apr 24, 2020
Visit Reason
The inspection was conducted as a COVID-19 Special Focus Survey 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 Infection Control Surveys conducted on April 17, 2020 and April 24, 2020.
Report Facts
Total residents: 26
Inspection Report Routine Census: 29 Deficiencies: 0 Apr 17, 2020
Visit Reason
The inspection was a COVID-19 Special Focus 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 Infection Control Surveys conducted on April 17, 2020 and April 24, 2020.
Report Facts
Total residents: 29
Inspection Report Renewal Census: 35 Deficiencies: 1 Jun 17, 2019
Visit Reason
A state licensure survey was conducted on June 17, 2019, as part of a re-licensure process for the assisted living center.
Findings
Deficiencies were found related to resident rights and medical care, specifically the failure to ensure physician-ordered medications were available and administered for one resident, resulting in potential for more than minimal harm. The facility submitted an acceptable plan of correction and a follow-up revisit was conducted on August 5, 2019, confirming correction of deficiencies.
Severity Breakdown
SS=E: 1
Deficiencies (1)
DescriptionSeverity
Failure to ensure physician ordered medications were available and administered for resident #3, resulting in potential for more than minimal harm.SS=E
Report Facts
Resident census: 35 Resident census: 39 Residents affected: 1 Residents reviewed: 8
Employees Mentioned
NameTitleContext
Karen ProctorAdministratorNamed in relation to plan of correction submission and signature
Sue DavisEnforcement CoordinatorSigned enforcement and follow-up letters
Lisa CalvinLong Term Care Enforcement ReviewerSigned acceptance letter of plan of correction
Inspection Report Renewal Capacity: 64 Deficiencies: 0 Mar 5, 2019
Visit Reason
This document is a license renewal issued to Cardinal Bay, Inc. for the operation of an Assisted Living Center located in Oklahoma City.
Findings
The document certifies the facility's license renewal and confirms the maximum licensed capacity of 64 beds. No deficiencies or findings are noted.
Report Facts
Maximum licensed beds: 64

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