Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Village during CMS and state inspections, most recent first.
A resident on supervised smoking with oxygen therapy was observed with cigarettes and a lighter left in the room despite staff stating smoking materials should be secured, and another resident with dementia and severe cognitive impairment eloped from the facility and was found in a nearby grocery store parking lot. Staff reported the exit doors were secured, rounds were done every two hours, and the resident was walking independently at the time of the elopement.
A resident with depression, atrial fibrillation, incontinence, pressure ulcer risk, and opioid pain medication use had an incomplete care plan. The care plan did not include focus areas or interventions for incontinence, skin integrity, or pain management, and the MDS coordinator and DON both confirmed it was incomplete.
Failure to assess and monitor pressure ulcers led to worsening wounds for a resident admitted with multiple wounds, including a stage II pressure ulcer, diabetes, and renal dialysis dependence. The record lacked an initial wound assessment and reassessments, while nursing notes later documented slough, rolled edges, odorous drainage, purulent drainage, and an unstageable sacral wound. The resident was sent to the hospital with cellulitis and severe sepsis, and surgery found a stage IV sacral wound.
Medication administration was not documented as ordered for a resident with epilepsy and heart failure. The resident had seizure activity after a levetiracetam dose change from 750 mg BID to 1000 mg BID, but the MAR did not show the evening dose or the next day’s two doses were given, and the DON stated there was no documentation that the medication was administered for those doses.
A resident with an indwelling urinary catheter was observed in a wheelchair with the catheter drainage bag attached to the back of the chair, while the bottom of the bag and part of the tubing rested on the floor in both the lobby and an outside smoking area. The resident had diagnoses including urine retention and diabetes mellitus, and a quarterly assessment showed a BIMS score of 14 and an indwelling catheter. The DON, CNA, and LPN stated catheter bags and tubing should be kept off the floor.
A resident with severe cognitive impairment and high elopement risk exited through a propped open door left unattended by a kitchen staff member, resulting in a fall on uneven ground and injuries that required hospital evaluation.
The facility did not conduct annual reviews of infection prevention and control policies, failed to assess or evaluate areas at risk for Legionella and other waterborne pathogens, and lacked both preventive measures and monitoring for waterborne pathogen control. These deficiencies were confirmed by the infection prevention coordinator and administrator, with no documentation available to show compliance.
Arbitration Agreements Lacked Neutral Arbitrator Language: The facility’s arbitration agreements for three residents did not state that a neutral arbitrator would be used, despite the facility policy requiring a neutral, qualified arbitrator agreed upon by both parties. Two residents were cognitively intact based on BIMS scores of 15, and one resident had severe cognitive impairment with a BIMS score of 7. The DON/administrator reviewed the agreements and stated they did not know why the neutral arbitrator language was missing.
The facility failed to complete quarterly MDS assessments within the required timeframe for three sampled residents. One resident’s BIMS was not completed because the quarterly assessment was already late, and two other residents had quarterly assessments completed late despite BIMS scores showing cognitive intactness. The MDS coordinator stated the delays were related to the prior MDS coordinator resigning and a lack of access to complete MDS assessments.
Late MDS Assessment Submission: The facility failed to submit two residents’ MDS assessments within the required timeframe. Both residents had BIMS scores of 15, and the assessments were completed late and then transmitted late because the MDS coordinator stated they did not know how to submit the assessments, so the regional office had been handling transmission.
A resident’s admission assessment was coded to show anticoagulant use during the look-back period, but the MAR did not show any anticoagulant administration and the MDS coordinator confirmed the item was coded in error. The resident had a BIMS score of 15 and a diagnosis of hemiplegia.
A resident with hemiplegia and hemiparesis, and a BIMS score indicating intact cognition, had restorative care ordered for a resting hand splint to the right hand. Although restorative care was documented in the chart and staff stated the resident was on restorative care, the care plan was not updated to include restorative care. The MDS coordinator confirmed the care plan had not been revised to reflect the restorative services.
Missing Annual CNA Performance Reviews: The facility failed to complete annual performance reviews and skills assessments for nurse aides employed over one year, including one CNA whose file lacked both documents in the past year. HR identified 13 CNAs employed over one year, and the administrator stated annual evaluations had not been done consistently until recently. The administrator in training said performance and skills assessments had not been consistently completed before their arrival and that they were unsure whether all had been updated.
The facility failed to maintain sanitary conditions in food storage, preparation, and service for 77 residents. Issues included improper storage of utensils, lack of beard guards, unclean equipment, and the use of unpasteurized eggs despite offering eggs prepared over easy.
A facility failed to maintain an infection prevention and control program for a resident with pressure ulcers. An LPN did not follow proper hand hygiene and infection control procedures during wound care, including not changing gloves or washing hands between tasks and placing supplies on an unclean surface. The DON confirmed these actions were not in compliance with the facility's hand hygiene policy.
The facility failed to ensure the PASRR for residents with serious mental health diagnoses was filled out correctly and referred to the OHCA. Two residents with PTSD had discrepancies between their PASRR Level I documentation and their quarterly assessments, which noted mental health diagnoses. The Administrator and ADON confirmed that OHCA should have been notified.
The facility failed to ensure that physicians responded to pharmacist medication reviews with a clinical rationale for three residents reviewed for unnecessary medications. Despite pharmacy recommendations to evaluate the use of certain medications, the physicians did not document a rationale for their decisions.
A facility failed to include fall risk and interventions in a baseline care plan for a resident with Alzheimer's, syncope, COPD, and COVID-19. Despite being assessed as high risk for falls, the resident's care plan lacked necessary precautions, leading to a fall incident. The MDS coordinator confirmed the omission, and a fall care plan was only initiated days later.
Smoking Materials Left Accessible and Resident Eloped From Facility
Penalty
Summary
The facility failed to ensure supervision for a resident who smoked and failed to secure smoking materials for a resident who was on supervised smoking. Resident #5 had diagnoses including oxygen therapy use and was identified in the baseline care plan and smoking assessment as a supervised smoker. Despite this, the resident was observed on 06/08/26 and again on 06/09/26 with cigarettes and a lighter on the overbed table in the room. The resident had a BIMS score of 15, indicating intact cognition for daily decision making. Facility staff, including the CMA, CNA, housekeeper, and DON, stated that supervised smokers should not have cigarettes or lighters in their room and that smoking materials should be kept in the medication room, although the ADON stated the resident was allowed to keep cigarettes in the room but not a lighter. The facility also failed to prevent elopement for a resident with severe cognitive impairment. Resident #9 had diagnoses including dementia and asthma, and a significant change assessment showed a BIMS score of 0, indicating severe impairment in cognition for daily decision making, while also noting the resident could walk independently. An incident report showed the facility received a call from police that the resident was next door in a grocery store parking lot. The resident was found outside the facility after the elopement, and the report stated all exit doors were secured at the time. The ADON stated they were on duty when the resident eloped, that rounds were made every two hours, and that there were eight staff members on duty when the police called.
Incomplete Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident. The resident had diagnoses including depression and atrial fibrillation, was cognitively intact with a BIMS score of 15, was always incontinent, was at risk for developing pressure ulcers, and received an opioid pain medication. Although the resident's care plan was revised, it did not include focus areas or interventions related to incontinence, skin integrity, or pain management. The MDS coordinator stated that a care plan should address the resident's care areas and preferences and confirmed that the resident's care plan was not complete, and the DON also stated that the care plan was incomplete.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with multiple wounds on admission, including a wound to the right buttock, left gluteal fold, left great toe, right heel deep tissue injury, right earlobe scab, upper lip wound, and a small wound to the top of the left foot. The resident’s record also showed diagnoses including a stage II pressure ulcer of the left buttock, dependence on renal dialysis, and diabetes mellitus. A physician’s order directed daily wound care to the buttocks wound, and later documentation described the wounds as improving, but the record did not show an initial assessment of the wounds or that the wounds were reassessed during the stay. Subsequent nursing documentation showed a change in the buttocks wound, including 95% slough, rolled skin edges, evidence of deterioration, and a large amount of brown odorous drainage on the bandage. The right ear lobe also had an open area, and a new order for betadine was obtained. A later weekly skin screen described an unstageable wound to the sacral region, a diabetic wound to the left great toe, an open area to the right ear lobe, and scabbing to the upper lip. Another wound care note documented large amounts of purulent drainage, after which the physician was notified and a wound culture and wound care provider assessment were ordered. The resident was then sent to the hospital, where the emergency department documented a large unstageable decubitus ulcer with cellulitis and severe sepsis, and surgery later found a stage IV sacral wound measuring 25 cm x 18 cm x 4 cm. The DON stated the resident’s wounds were not adequately monitored and assessed.
Medication Administration Not Documented for Ordered Anticonvulsant
Penalty
Summary
The facility failed to ensure medications were administered as ordered for 1 of 3 sampled residents reviewed for medications. The resident had diagnoses including epilepsy and heart failure and was ordered levetiracetam 750 mg by mouth twice daily for epilepsy on admission. That order was discontinued and a new order was written for levetiracetam 1000 mg by mouth twice daily after the resident had seizure activity multiple times in one day. Nursing documentation showed the increased dose was not available in the facility, and the pharmacy reported it would not be delivered until the following day, although another note later stated it would be delivered that night. The MAR showed the resident received the 750 mg dose on one morning and the 1000 mg dose on a later morning, but did not show administration of levetiracetam for the evening dose on one day or the two doses on the next day. The DON stated the facility did not have documentation that the levetiracetam was administered for those missed doses.
Catheter drainage bag and tubing rested on the floor
Penalty
Summary
Infection control was not maintained for a resident with an indwelling urinary catheter. On 06/04/26, Res #8 was observed in the lobby seated in a wheelchair with the catheter drainage bag attached to the back of the wheelchair, with the bottom of the drainage bag and part of the tubing resting on the floor. The same condition was observed later that day in the outside smoking area, with the bottom of the catheter drainage bag and part of the tubing again resting on the floor. The resident’s record showed diagnoses including urine retention and diabetes mellitus, and a quarterly assessment dated 05/05/26 documented a BIMS score of 14 and the presence of an indwelling urinary catheter. The facility’s DON, CNA #1, and LPN #1 stated that catheter bags and drainage tubing should be kept off the floor.
Resident Elopement and Fall Due to Propped Open Door
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement exited the facility through a side door that had been propped open by a kitchen staff member. The resident, who had diagnoses including anxiety and vascular dementia and a BIMs score indicating severe cognitive impairment, was able to leave the building unsupervised due to the door being left open. The resident subsequently fell on uneven ground outside the facility and sustained cuts and abrasions, requiring transport to a hospital for evaluation and treatment. The incident was discovered when dietary staff notified nursing staff of the resident's fall outdoors. Facility records indicated that the door was propped open for less than a minute while the staff member took out the trash, but this lapse in protocol allowed the resident to exit unnoticed. The staff member acknowledged breaking facility policy by leaving the door open, which had been locked for safety reasons. The event was reported to the state health department as required.
Failure to Review and Implement Waterborne Pathogen Prevention Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several deficiencies. The infection prevention coordinator and administrator confirmed that infection prevention and control policies and procedures, including those related to Legionella surveillance, had not been reviewed or updated annually, with no documentation of any recent reviews. Additionally, there was no facility assessment or evaluation in place to identify locations where Legionella or other waterborne pathogens could grow and spread, nor were there measures implemented to prevent the growth of such pathogens. The facility also lacked a monitoring process to evaluate the effectiveness of any water pathogen prevention program. At the time of the survey, 64 residents resided in the facility.
Arbitration Agreements Lacked Neutral Arbitrator Language
Penalty
Summary
The facility failed to ensure its arbitration agreement provided for the selection of a neutral arbitrator for 3 of 3 sampled residents whose agreements were reviewed. The facility’s undated policy stated that arbitration is a binding process where a neutral third party hears and resolves disputes outside of court, and that arbitration would be conducted by a neutral, qualified arbitrator agreed upon by both parties. However, the arbitration agreement signed by Resident #2’s representative did not show that a neutral arbitrator would be utilized, even though an admission assessment later showed the resident had a BIMS score of 15 and was cognitively intact for daily decision making. The arbitration agreement signed by Resident #11 also did not show that a neutral arbitrator would be utilized, and a quarterly assessment showed a BIMS score of 15. Resident #71’s arbitration agreement, signed by the resident’s representative, likewise did not show that a neutral arbitrator would be utilized; an admission assessment showed a BIMS score of 7, indicating severe cognitive impairment for daily decision making. The administrator stated they had reviewed the facility’s arbitration agreement and did not know why it did not contain verbiage that a neutral arbitrator would be utilized.
Late Quarterly Assessments and Missed BIMS Completion
Penalty
Summary
The facility failed to ensure quarterly assessments were completed within 14 days of the assessment reference date for 3 of 20 sampled residents. For Resident #6, a quarterly assessment dated 06/17/25 showed that a BIMS assessment had not been conducted, and the BIMS was not completed until 07/12/25. The MDS coordinator stated on 08/10/25 that the BIMS could not be completed because the quarterly assessment had been completed late and they were outside the timeframe to obtain a BIMS score; they also stated the quarterly MDS was late because the previous MDS coordinator had resigned, access to complete MDS assessments was unavailable for a period of time, and they had gotten behind. For Resident #27, a quarterly/discharge return not anticipated assessment dated 07/01/25 showed a BIMS score of 15, indicating cognitive intactness for daily decision making, but the assessment was completed late on 07/20/25. For Resident #28, a quarterly assessment dated 06/29/25 showed a BIMS score of 15 and was also completed late on 07/20/25. The MDS coordinator stated for both residents that the assessments were late because the previous MDS coordinator had resigned and they had not had access to complete MDS assessments.
Late MDS Assessment Submission
Penalty
Summary
The facility failed to ensure MDS assessments were submitted to the State within 14 days of completion for 2 of 20 sampled residents. Resident #27 had a quarterly/discharge return not anticipated assessment dated 07/01/25 with a BIMS score of 15, indicating the resident was cognitively intact for daily decision making; the assessment was completed late on 07/20/25 and the MDS 3.0 NH Final Validation Report dated 08/05/25 showed it was submitted late. Resident #28 had a quarterly assessment dated 06/29/25 with a BIMS score of 15, indicating the resident was cognitively intact for daily decision making; that assessment was also completed late on 07/20/25 and the validation report dated 08/05/25 showed it was submitted late. On 08/10/25, the MDS coordinator stated the assessments had been submitted/transmitted late on 08/05/25 and that the regional office had been transmitting assessments because the coordinator had not known how to submit them.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure an accurate assessment for Resident #2. The admission assessment dated 05/17/25 showed the resident had a BIMS score of 15, a diagnosis of hemiplegia, and was coded as taking an anticoagulant during the seven-day look-back period. However, the MAR for 05/01/25 through 05/31/25 did not show that the resident received an anticoagulant medication during that period. During review on 08/10/25, the MDS coordinator reviewed the admission assessment, physician orders, and MAR and stated the assessment had been coded in error regarding anticoagulant medication, and that Resident #2 had not been ordered or received an anticoagulant during the look-back period.
Care Plan Not Updated to Include Restorative Care
Penalty
Summary
The facility failed to ensure the care plan was updated for Resident #2, whose care plan dated 05/09/25 did not include restorative care. The resident’s admission assessment dated 05/17/25 showed diagnoses including hemiplegia and hemiparesis, and a BIMS score of 15 indicating the resident was cognitively intact. A restorative care order dated 07/07/25 directed that a resting hand splint be applied daily to the right hand and removed after 6-8 hours, and a progress note on the same date documented restorative care treatment with application of the splint to the resident’s right hand. On 08/10/25, the admissions coordinator stated the resident was on restorative care and that the restorative aide provided the care, but also stated they would need to train someone to provide the care when the aide was not in the facility. Later that day, MDS coordinator #1 stated that when restorative care adds a resident to their care list, they update the care plan to include restorative care, and confirmed Resident #2’s care plan had not been updated to include restorative care.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews and skills assessments for nurse aides hired over one year ago, including CNA #1, who was one of two employee files reviewed and did not have an annual performance review or skills assessment completed in the past year. Human resources identified 13 CNAs who had been employed for over one year. During interview, CNA #1 stated they worked only weekends and were not aware of having completed any annual performance review or skills checklist in the past year. The administrator stated they had not been doing annual evaluations until recently, and the administrator in training stated performance and skills assessments had not been consistently completed before their arrival a few months earlier and that they were trying to get them all completed but were not sure if all had been updated.
Sanitary Conditions in Food Service
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions for 77 residents. Observations revealed several deficiencies: a scoop was left in the sugar bin, a staff member with a beard was not wearing a beard guard, and the dish machine had accumulated dust and dirt. Additionally, a can of soda had burst open in the freezer, and the stove had a black substance layer on the bottom and a large amount of brown substance on the inside. The cook admitted there was no current cleaning schedule, and the last documented cleaning was in November. During a meal service observation, it was noted that the facility had two cases of unpasteurized eggs but no pasteurized eggs available, despite offering eggs prepared over easy. The dietary supervisor confirmed that only unpasteurized eggs had been received in the recent food delivery and was unsure when the last pasteurized eggs had been received. These actions and inactions led to the deficiency in maintaining sanitary conditions in food storage, preparation, and service.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident with pressure ulcers. The resident had diagnoses including hemiplegia, hemiparesis, type 2 diabetes mellitus, and pain, and had a documented stage 2 pressure ulcer on the right ankle. During a wound care observation, an LPN did not follow proper hand hygiene and infection control procedures. The LPN placed supplies on an unclean bedside table, did not change gloves or wash hands between tasks, and used the same gloves to handle different areas of the resident's body and open new packages. The LPN only used alcohol hand gel after exiting the room, which was not in compliance with the facility's hand hygiene policy. The Director of Nursing (DON) confirmed that the LPN should have provided a clean surface for supplies and changed gloves and washed hands between tasks. The facility's hand hygiene policy required staff to perform proper hand hygiene to prevent the spread of infection, including washing hands after handling contaminated objects and before and after removing personal protective equipment. The LPN acknowledged the failure to change gloves or wash hands between tasks during the wound care procedure.
Failure to Ensure Accurate PASRR Documentation and Referral
Penalty
Summary
The facility failed to ensure the PASRR for residents with serious mental health diagnoses was filled out correctly and referred to the OHCA. Resident #14, admitted with diagnoses including PTSD, COPD, A-Fib, Depression, and alcohol abuse, had a PASRR Level I dated 06/13/23 that documented no mental health diagnosis, while a quarterly assessment dated 01/09/24 documented a mental health diagnosis. Similarly, Resident #25, admitted with diagnoses including PTSD, heart failure, HTN, dementia, obstructive sleep apnea, DM, and GERD, had a PASRR Level I dated 10/12/23 that documented no mental health diagnosis, while a quarterly assessment dated 01/11/24 documented a mental health diagnosis. The Administrator and ADON confirmed that OHCA should have been notified of the mental health diagnoses of PTSD for both residents.
Failure to Document Clinical Rationale for Medication Reviews
Penalty
Summary
The facility failed to ensure that physicians responded to pharmacist medication reviews with a clinical rationale for three of five sampled residents reviewed for unnecessary medications. Resident #1, admitted with diagnoses including hypertension, dementia, and depression, had pharmacy recommendations to evaluate the use of Glimeperide and a combination of opioid and gabapentinoid, but the physician did not document a rationale. Resident #25, with diagnoses such as heart failure, diabetes mellitus, hypertension, dementia, PTSD, and obstructive sleep apnea, had a pharmacy recommendation to evaluate the use of an opioid with a gabapentinoid, but again, no rationale was documented by the physician. Resident #34, admitted with diagnoses including depression, COPD, diabetes mellitus, Parkinson's, anxiety, and hypertension, had a pharmacy request to evaluate the use of an opioid with a gabapentinoid, but the physician did not document a rationale. The Director of Nursing confirmed that the GDRs should have included a rationale from the physician.
Failure to Include Fall Risk in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan included fall risk and interventions for a resident admitted with diagnoses including Alzheimer's disease, syncope and collapse, COPD, and COVID-19. Despite a fall risk assessment indicating the resident was at high risk for falls, the baseline care plan initiated did not document this risk or include any fall interventions. This oversight led to an incident where the resident was found on the floor by a nurse, having apparently rolled from their bed. Although no injuries were reported, a concave mattress was applied as a fall intervention following the incident. The deficiency was further highlighted when the MDS coordinator confirmed that fall risk and precautions should have been included in the baseline care plan but were not. The resident's admission MDS documented that they were cognitively intact, used a walker, and required partial assistance with transfers and walking. The fall care plan was only initiated several days after the incident, including various interventions such as frequent checks, assistance with transfers, and physical therapy evaluation.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sapulpa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beacon Ridge | 1 mi | ★★★★★ | 1 | 0 |
| The Gardens | 2 mi | ★★★★★ | 7 | 0 |
| Covenant Living At Inverness | 7.1 mi | ★★★★★ | 1 | 0 |
| Glenwood Skilled Nursing And Therapy | 7.8 mi | ★★★★★ | 0 | 0 |
| Grace Skilled Nursing And Therapy Jenks | 9 mi | ★★★★★ | 3 | 0 |
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