Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
55 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 2
Aug 29, 2025
Visit Reason
The inspection was conducted to review the facility's compliance with assessment requirements for residents, including completion and accuracy of assessments.
Findings
The facility failed to complete a discharge assessment for one resident and inaccurately coded a significant change MDS assessment for another resident, both issues involving minimal harm and affecting a few residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure assessments were completed for 1 (#20) of 16 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately code a significant change MDS assessment for 1 (#41) of 14 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents identified in facility: 55
Sampled residents for assessment completion: 16
Sampled residents for assessment accuracy: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS coordinator #1 | Stated the discharge assessment should have been completed and acknowledged the inaccurate coding of the significant change MDS assessment. | |
| administrator | Identified the number of residents and stated expectations for accurate MDS coding. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
May 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify responsible parties immediately after an accident/fall and failure to develop a comprehensive care plan including assistance needed for incontinent care and bed mobility.
Findings
The facility failed to notify the responsible party immediately after a resident's fall and failed to develop a care plan specifying the amount of assistance needed for incontinent care and bed mobility for the resident. The resident sustained a fall with major injury requiring hospitalization and two-person assistance was inconsistently provided and documented.
Complaint Details
The complaint investigation revealed that Resident #1 fell out of bed during incontinent care on 02/23/25 and the facility failed to notify the resident's family immediately. The resident sustained a fracture and other injuries requiring hospitalization. The facility also failed to develop a care plan specifying the amount of assistance needed for bed mobility and incontinent care, leading to inconsistent staff assistance and increased fall risk.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure responsible parties were notified immediately after an accident/fall for 1 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a complete care plan that includes the amount of assistance needed for incontinent care and bed mobility for 1 of 3 sampled residents. | Level of Harm - Actual harm |
| Failed to ensure residents were free from falls during incontinent care for 1 of 3 sampled residents. | Level of Harm - Actual harm |
Report Facts
Residents present: 56
Resident height: 63
Resident weight: 235
Documentation Survey Report - toileting/incontinent care: 52
Documentation Survey Report - bed mobility: 77
Documentation Survey Report - toileting/incontinent care: 38
Documentation Survey Report - bed mobility: 52
Residents requiring two staff assistance: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in notification failure and fall incident. |
| CNA #1 | Certified Nursing Assistant | Notified nurse of fall and involved in incontinent care at time of fall. |
| RN care coordinator #1 | RN Care Coordinator | Provided statements regarding resident care and assistance needs. |
| DON | Director of Nursing | Provided statements on notification policies, care plans, and staff training. |
| MDS coordinator | Minimum Data Set Coordinator | Provided assessment and documentation review regarding resident assistance needs. |
| CMA #1 | Certified Medication Aide | Observed providing incontinent care to Resident #1. |
| CNA #2 | Certified Nursing Assistant | Observed providing incontinent care and stated use of two person assistance. |
| CNA #3 | Certified Nursing Assistant | Provided statements about assistance needs before and after fall. |
| CNA #4 | Certified Nursing Assistant | Provided statements about assistance needs. |
| CNA #5 | Certified Nursing Assistant | Provided statements about assistance needs before and after fall. |
| CNA #6 | Certified Nursing Assistant | Provided statements about assistance needs and staff inservice. |
| family member #1 | Provided statements about notification delay and assistance needs. | |
| family member #2 | Provided statements about resident's condition and hospitalization. |
Inspection Report
Renewal
Census: 17
Deficiencies: 1
Mar 6, 2025
Visit Reason
A relicensure survey was conducted from March 5 through March 6, 2025, to assess compliance with applicable construction and safety standards for the assisted living center.
Findings
The facility failed to ensure an annual fire inspection was completed in 2024, with no documentation available for a 2024 fire marshal inspection. The last inspection was completed on October 6, 2023. The facility submitted a plan of correction which was accepted, and a revisit confirmed substantial compliance as of March 13, 2025.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure an annual fire inspection was completed in 2024. | SS=F |
Report Facts
Facility Census: 17
Date of last fire marshal inspection: Oct 6, 2023
Date of accepted correction: Mar 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James M Jakubovitz | Administrator | Signed the plan of correction |
| Tempal Killman | Enforcement Analyst | Signed enforcement letters and correspondence |
Inspection Report
Routine
Census: 58
Deficiencies: 7
Apr 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, abuse prevention, care planning, discharge procedures, safety, laboratory services, and food handling at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to report injuries of unknown origin, failure to revise care plans accurately, failure to provide discharge summaries, unsecured harmful chemicals, failure to obtain ordered lab tests, and improper food labeling and storage.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to speak to a resident in a respectful manner and ensure resident clothing labels were not visible. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report an injury of unknown origin to the state authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to revise care plans accurately for residents within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a discharge summary was developed for a discharged resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure harmful chemicals were secured in the nursing home area. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain physician ordered laboratory tests for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food items were properly secured, dated, and labeled. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 58
Residents requiring wander guards: 6
Bruise size: 15
Bruise size: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Prepared incident report for Resident #52's injury of unknown origin | |
| CNA #6 | Observed speaking disrespectfully to Resident #28 | |
| CNA #3 | Provided statements regarding dignity and clothing labeling practices | |
| Laundry #1 | Described labeling practices for resident clothing | |
| MDS Coordinator #1 | Discussed care plan updates and deficiencies | |
| LPN #3 | Provided information about Resident #22's hospice status | |
| Dietary Aide #1 | Commented on food labeling and access to chemical storage | |
| Dietary Manager | Discussed chemical storage door locking practices | |
| DON | Director of Nursing | Provided census information, described investigation and reporting practices, and discussed lab and discharge procedures |
Inspection Report
Renewal
Deficiencies: 1
Oct 6, 2023
Visit Reason
A relicensure survey was conducted from October 4, 2023 through October 6, 2023 to assess compliance with assisted living center regulations.
Findings
The facility failed to ensure medications were reviewed monthly by a registered nurse or pharmacist for six of six sampled residents. The Director of Nursing stated the pharmacist reviewed medications quarterly and was unaware monthly reviews were required.
Severity Breakdown
Level B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure medications were reviewed monthly by an RN or pharmacist for six sampled residents. | Level B |
Report Facts
Residents receiving medications: 15
Sampled residents with medication review deficiency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James M. Jakubovitz | Administrator | Named as the facility administrator in the plan of correction and correspondence. |
| Lisa Calvin | Enforcement Analyst II | Signed enforcement correspondence related to the inspection. |
| Tempal Killman | Administrative Assistant II | Signed letter acknowledging acceptance of plan of correction. |
Inspection Report
Routine
Deficiencies: 9
Feb 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, fall prevention, respiratory care, and other aspects of resident care at the nursing home.
Findings
The facility failed to ensure accurate resident assessments for falls and PEG tube feeding, develop baseline care plans within 48 hours of admission, create comprehensive care plans for residents with PEG tubes, falls, and venous ulcers, revise fall care plans after incidents, obtain weights as ordered for a resident with congestive heart failure, document communication with hospice, and follow physician orders for oxygen therapy. Several residents had multiple falls without updated care plans or interventions, and oxygen tubing was not labeled or changed as ordered.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure resident assessments were accurate for falls and PEG tube feeding. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a baseline care plan within 48 hours of admission for a new resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans for residents with PEG tubes, falls, and venous ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise fall care plans after multiple falls for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain and document daily weights as ordered for a resident with congestive heart failure. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document communication between hospice and facility for a resident on hospice. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure care plan accuracy for a resident with PEG tube regarding eating interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow fall protocol policy and provide adequate supervision and interventions to prevent falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's orders for oxygen therapy including changing and labeling oxygen tubing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with falls in last 12 months: 56
Residents admitted in last year: 121
Residents with congestive heart failure: 13
Residents on hospice: 2
Weights not documented: 6
Falls for resident #13: 11
Falls for resident #8: 11
Falls for resident #28: 17
Inspection Report
Renewal
Census: 13
Deficiencies: 6
Mar 28, 2019
Visit Reason
A state licensure survey was conducted on March 28, 2019, as part of a re-licensure inspection of the assisted living center facility.
Findings
Deficiencies were found related to assessment timeframes, use of assessment, medication staffing, quality assurance committee, and maintenance of records. The deficiencies represented the potential for more than minimal harm. A follow-up survey was conducted on June 20, 2019, and all deficient practices were cleared.
Severity Breakdown
SS=E: 3
SS=F: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to complete admission assessments within thirty days before or at the time of admission for sampled residents. | SS=E |
| Failed to complete comprehensive assessments within required timeframes for sampled residents. | SS=E |
| Failed to use assessment results to develop care plans for sampled residents. | SS=E |
| Failed to ensure monthly medication reviews by a registered nurse or pharmacist and quarterly medication reviews by a consultant pharmacist for residents. | SS=F |
| Failed to establish and maintain an internal quality assurance committee that meets at least quarterly. | SS=F |
| Failed to maintain organized, accurate clinical records for sampled residents. | SS=F |
Report Facts
Current census: 13
Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Calvin | Long Term Care Enforcement Reviewer | Signed acceptance letter of plan of correction |
| Sue Davis | Enforcement Coordinator | Signed letter regarding informal dispute resolution process and follow-up survey results |
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