Inspection Report Summary
The most recent inspection on November 13, 2025, identified deficiencies related to medication administration errors, specifically an incorrect dose given to one resident. Earlier inspections showed a mixed pattern, with prior deficiencies involving safety checks, incident reporting, staffing, and medication management, but several complaint investigations found no deficiencies. Main themes across citations included medication administration, resident safety checks, and documentation issues. Complaint investigations were mostly unsubstantiated, except for a substantiated neglect finding in 2022 related to missed safety checks. The facility’s inspection history shows some recurring issues with medication and safety protocols, with no enforcement actions or fines listed in the available reports.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
40 residents
Based on a November 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
| Name | Title | Context |
|---|---|---|
| Advanced Certified Medication Aide (ACMA) | Observed administering incorrect medication dose to resident #8 | |
| Karen Proctor | Administrator | Named in correspondence related to inspection and plan of correction |
| Tempal Killman | Enforcement Analyst | Signed enforcement and follow-up letters |
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Date: 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
Date: Jan 8, 2024
Visit Reason
A complaint investigation was conducted due to an allegation that the facility failed to protect residents from sexual abuse.
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.
Findings
The investigation found no deficiencies. Residents and staff interviews, observations, and record reviews indicated that residents felt safe and no abuse was identified.
Report Facts
Sample residents selected: 3
Facility census: 36
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Failed to provide safety checks every two hours per the service plan for three residents (#5, #6, and #8).
Failed to submit an incident report to the Oklahoma State Department of Health related to an elopement for one resident (#6).
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
| Name | Title | Context |
|---|---|---|
| Alisha Conley | Clinical Health Facility Surveyor | Signed complaint investigation report |
| Katie Stagner | Enforcement Analyst | Signed enforcement process letters |
| Tempal Killman | Administrative Assistant II | Signed letter accepting plan of correction |
| Lisa Calvin | Enforcement Analyst | Signed letter confirming correction of deficiencies |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Date: Dec 21, 2022
Visit Reason
A complaint investigation was conducted due to an allegation that the center failed to ensure residents were not neglected.
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.
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.
Deficiencies (1)
Failure to provide safety checks every two hours per the service plan for three residents reviewed for neglect.
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
| Name | Title | Context |
|---|---|---|
| Andrew Conley | Clinical Health Facility Surveyor | Signed the investigative report dated 2022-12-22. |
| Katie Stagner | Enforcement Analyst | Signed enforcement correspondence and follow-up letters. |
| Tempal Killman | Administrative Assistant II | Signed letter accepting plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation at the Assisted Living facility.
Complaint Details
Complaint investigation conducted; no deficiencies were cited.
Findings
No deficiencies were cited during the complaint investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Stagner | Long Term Care Enforcement Reviewer | Signed the complaint investigation report. |
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (3)
Failure to disclose one-person staffing and have an approved plan for emergent situations, with potential for harm to residents.
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.
Failure to maintain an organized, accurate clinical record for residents, including lack of documentation of medication orders, resident behaviors, falls, and transfers.
Report Facts
Investigation dates: 2021-05-24 to 2021-05-25
Total residents: 27
Plan of correction completion date: Aug 1, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Edmiaston | RN, BSN | Signed the complaint investigation reports dated 05/26/2021 |
| Karen Proctor | Administrator | Facility administrator named in correspondence and plan of correction |
| Tempal Killman | Administrative Assistant, Long Term Care Enforcement | Signed letters regarding plan of correction acceptance and requests |
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Date: 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.
Deficiencies (1)
Failure to ensure physician ordered medications were available and administered for resident #3, resulting in potential for more than minimal harm.
Report Facts
Resident census: 35
Resident census: 39
Residents affected: 1
Residents reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Proctor | Administrator | Named in relation to plan of correction submission and signature |
| Sue Davis | Enforcement Coordinator | Signed enforcement and follow-up letters |
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed acceptance letter of plan of correction |
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Date: 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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