Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franciscan Villa during CMS and state inspections, most recent first.
A resident with depression, chronic pain, and multiple psychotropic and pain medications called a suicide hotline, reported feeling isolated, and disclosed hoarding acetaminophen with intent for self-harm. The ADON documented the hotline contact and a behavior monitoring order was entered to track episodes of sadness, suicidal thoughts, suicidal tendencies, and agitation, with findings to be documented and the provider notified. Despite this order and a facility policy requiring mood and behavior monitoring and documentation after suicide threats, the administrator later acknowledged that no behavior monitoring documentation could be found. That same evening, after a second hotline call and an assessment by an LPN, the resident’s roommate reported the resident was shaking a pill bottle and threatening to take all the pills; the LPN then found an empty pill bottle and the resident was sent to the ER. Interviews with staff and family confirmed that medication remained at the bedside and that staff believed the issue was resolved, but there was no documented ongoing behavior monitoring as ordered.
A resident with intact cognition, hemiplegia/hemiparesis, and CKD stage 3 was found with antifungal cream on the bedside table, despite having only an order for staff to apply the cream every shift and no documented authorization to self-administer medications. Facility policy required an interdisciplinary team assessment and a completed Medication Self-Administration Assessment Form in the medical record before any self-administration, but no such assessment or physician order to self-medicate was found. An LPN stated they did not know who provided the cream to the resident and confirmed there was no self-application order, and the administrator reported being unable to locate a self-administration assessment, demonstrating the facility’s failure to follow its own self-administration policy.
The facility failed to secure medication carts, as observed on two occasions where treatment carts were left unlocked and unattended. Staff, including an LPN, were seen accessing the carts without locking them afterward, despite acknowledging that the carts should be locked.
The facility failed to provide palatable meals, as reported by three residents. A resident stated the food was not hot in the dining room and cold in their room. Another resident found the food tasted bad, while a third resident described the food as cold, bad-tasting, and sometimes inedible. A test tray showed the food was not at appropriate temperatures, and the bread was stale. The dietary manager admitted the bread was left to proof too long.
Failure to Monitor and Document Suicidal Ideation per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document a resident’s behavior according to a physician’s order following suicidal ideation. The resident had a history of depression, with an admission assessment showing a depression score of 8 indicating mild depression and intact cognition, and was receiving multiple psychotropic and pain medications, including Oxycodone for pain and various antidepressants and dementia medications. On the day of the incident, the suicide hotline notified the facility that the resident had called, reported feeling isolated, and was contemplating ending their life, disclosing that they were hoarding acetaminophen with the intent to use it for self-harm. The ADON documented this contact and noted that an order for behavior monitoring was put into place, including monitoring episodes of sadness, suicidal tendencies, suicidal thoughts, and agitation, with documentation of all findings and immediate provider notification. Despite the physician’s order for behavior monitoring, the facility was unable to produce behavior monitoring documentation for this resident. The administrator later stated they were unable to find any behavior monitoring documentation, even though an order had been transcribed to monitor the resident’s mood and suicidal tendencies starting that evening. The facility’s own Suicide Threats policy required staff to monitor the resident’s mood and behavior and document details of the situation objectively in the medical record until a physician determined that suicide risk was no longer present. However, the record review and interviews did not show evidence that such ongoing monitoring and documentation occurred after the order was initiated. Following the initial suicide hotline call, staff actions focused on immediate assessment, removal of bedside medication by instructing the family to take it home, and arranging for a bed bath and potential activity changes, but there is no documented pattern of behavior monitoring as ordered. Later that same evening, the suicide hotline called again, and an LPN assessed the resident, who stated they were fine and declined hospital evaluation. Shortly afterward, the roommate reported that the resident was shaking a pill bottle and threatening to take all the pills; the LPN then found the resident with an empty pill bottle, and 911 was called for hospital transport. Interviews with the administrator confirmed that behavior monitoring documentation could not be located, supporting the finding that the facility failed to ensure the resident’s behavior was monitored and documented in accordance with the physician’s order and facility policy. The resident’s family members reported that the resident had been in significant, chronic pain, was very depressed, and had previously expressed thoughts about not wanting to live that way, although they were unsure whether the facility knew of this past suicidal ideation. Staff interviews indicated that the ADON believed the situation was resolved after the initial assessment and education about removing medications from the room, and that they relied on the family member to remove the acetaminophen. CNA and family interviews confirmed that a bottle of Tylenol or aspirin remained at the bedside and that the family member forgot to take it home. These accounts, combined with the absence of documented behavior monitoring after the suicide hotline notifications and the physician’s order, form the basis of the cited deficiency for failure to provide treatment and care according to orders and the resident’s needs.
Failure to Assess and Authorize Resident Self-Administration of Topical Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team determined that a resident could safely self-administer a topical medication before allowing self-administration. Surveyors observed that Resident #2 had an antifungal cream on their bedside table, and the facility’s policy stated that residents may only self-administer medications after an interdisciplinary team assessment is completed and documented on a Medication Self-Administration Assessment Form in the medical record. Resident #2 had a physician’s order for antifungal external cream 2% to be applied to the groin every shift for redness and had a quarterly assessment showing a BIMS score of 13, indicating intact cognition, with diagnoses including hemiplegia or hemiparesis and chronic kidney disease stage 3. However, there was no self-administration of medication assessment or physician order to self-medicate in the electronic medical record. An LPN reported not knowing who gave the resident the antifungal cream and acknowledged that while cognitively intact residents could have an order to apply creams themselves, this resident did not have such an order, and the administrator confirmed they were unable to locate a medication self-administration assessment for this resident. This sequence of observations, record reviews, and staff interviews showed that the facility did not follow its own policy requiring an interdisciplinary assessment and physician order before allowing a resident to self-administer medication, resulting in the identified deficiency for one of six sampled residents reviewed for medication administration.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that medications were stored in locked compartments as required. On two separate occasions, an unlocked and unattended treatment cart was observed on the resident hall. On the first occasion, multiple staff members walked past the unlocked cart without securing it. An LPN was observed removing items from the cart without locking it afterward. The LPN acknowledged that the cart should have been locked but was unsure why it was not. On the second occasion, another LPN confirmed that the treatment cart should not be left unlocked.
Failure to Provide Palatable Meals
Penalty
Summary
The facility failed to provide palatable meals to residents, as evidenced by observations and interviews with three residents. Resident #37 reported that the food did not taste good and was warm but not hot in the dining room, and cold when served in their room. Resident #23 stated that the food tasted bad. Resident #4 mentioned that the food served in their room was cold, tasted bad, and was sometimes inedible. Additionally, Resident #4 received items on their tray that were marked not to be served to them, and when they requested an alternative, they were informed that the kitchen was closed. A test tray evaluation revealed that the barbecued pulled pork was barely warm, the coleslaw was barely cool, and the baked beans were at a good temperature but had a vinegar-like aftertaste. The bread was warm but chewy and tasted somewhat stale, as if it were day-old bread. The dietary manager acknowledged that the bread was left to proof too long.
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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 Broken Arrow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broken Arrow Nursing Home, Inc | 2.4 mi | ★★★★★ | 1 | 0 |
| Cedarcrest Care Center | 2.8 mi | ★★★★★ | 1 | 0 |
| Aspen Health And Rehab | 3.1 mi | ★★★★★ | 0 | 0 |
| Village Health Care Center | 3.7 mi | ★★★★★ | 10 | 1 |
| Forest Hills Care And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.