Arbor Village: Dementia Resident Fell After Door Propped Open - OK
The resident, identified in inspection records as Resident 69, had vascular dementia and an anxiety diagnosis. A cognitive assessment from February 2025 gave them a score of 5 on the Brief Interview for Mental Status, a level that indicates severe impairment in daily decision making. A separate elopement evaluation from March 2025 scored the resident at 9, placing them at risk for leaving the facility, though staff noted at the time that while the resident walked around the building, they had not shown exit-seeking behavior.
On the evening of April 24, 2025, dietary staff told nursing staff that the resident had fallen outside. The resident was transported to a hospital for evaluation and treated for cuts and abrasions.
The door they walked through was ordinarily locked.
A facility incident report filed with the Oklahoma State Department of Health described what happened: a kitchen staff member had propped the side door open to remove trash, and the resident walked out through it and fell on uneven ground outside.
The cook, identified in records only as Cook 1, told inspectors on August 10 that it was the first time they had ever propped that door open to take out trash. They said the door was open for less than a minute. "I regretted propping open the door," the cook told inspectors, "and would not do it again."
The admissions coordinator put it more bluntly. The staff member should not have left the door propped open, they said. "There was a reason the door was locked in the first place. They broke facility protocols for protecting the safety of the resident."
What followed the April incident was not an immediate reckoning. By the time federal inspectors arrived in August, the administrator who had conducted the internal investigation was gone. An administrator in training told inspectors on August 7 that they had inherited the completed investigation from their predecessor. The finding, they said, was that Cook 1 had been educated on resident safety and facility policies and was allowed to return to work.
That was the response: a conversation, and then back to the kitchen.
Federal inspectors cited the facility for failing to provide an environment free of accident hazards, a deficiency classified at the level of actual harm. The inspection, a complaint survey, covered 20 sampled residents and focused on accident hazard review. Arbor Village housed 84 residents at the time.
The facility sits at 310 West Taft Avenue in Sapulpa, a city of roughly 20,000 people about 15 miles southwest of Tulsa.
What the inspection record does not resolve is how a door that was supposed to be locked, in a facility housing residents at documented risk for elopement, had no mechanism preventing it from being propped open. The cook said it took less than a minute. For a resident with a dementia score indicating severe cognitive impairment, a minute and an open door were enough.
The resident went to the hospital. The cook went back to work. The previous administrator left. And the door, for that minute in April, stood open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbor Village from 2025-08-10 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
Arbor Village in Sapulpa, OK was cited for violations during a health inspection on August 10, 2025.
The resident, identified in inspection records as Resident 69, had vascular dementia and an anxiety diagnosis.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.