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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Village Health Care Center during CMS and state inspections, most recent first.
A resident did not have a required comprehensive care plan completed within the timeframe specified by facility policy following completion of the admission MDS assessment. Record review showed that although the admission assessment was completed, no comprehensive care plan was present in the EMR, and only an undated baseline care plan was available. In interviews, the MDS coordinator acknowledged that a comprehensive care plan had not been developed for the resident, and the administrator confirmed that only the baseline care plan could be found and that they were aware the comprehensive care plan was not done.
A resident with Huntington’s disease, anxiety, depression, delusions, and a documented high risk for wandering repeatedly eloped from the facility despite an existing care plan and wandering risk evaluation. The resident left the building on multiple occasions, including episodes where they fell in a field, were found at a hotel, intentionally burned the back of their hand while away, and were located by police at a known drug house and by family at a local business. Staff consistently relied on q15-minute visual checks as the primary intervention after each elopement, did not update the care plan with new interventions, and did not conduct root-cause investigations of the elopements. The DON later acknowledged that the q15-minute checks were not effective, and camera reviews showed discrepancies between staff reports of last contact and the actual time the resident exited the building.
A resident did not receive a required quarterly MDS assessment within three months of the admission assessment. Record review showed multiple documented assessments and entries, but no quarterly assessment after admission. An LPN temporarily responsible for MDS assessments and care plans while the MDS coordinator was on leave reported being unaware that the quarterly MDS for this resident was due, and the DON confirmed the assessment was late because the interim MDS nurse did not complete the required duties.
A resident with an identified elopement risk had an elopement care plan initiated but it was never reviewed or revised after multiple subsequent elopement incidents. Record review showed no updates to the original elopement interventions, and staff interviews confirmed that the care plan had not been changed. An LPN believed the DON had recently updated the plan, while the DON stated the plan was not updated because an interim MDS nurse did not perform required duties.
Routine safety inspections of bed frames and bed rails were not conducted for several residents using beds with attached side rails. Maintenance staff confirmed that no inspections or records existed and expressed confusion about what qualified as a bed rail, despite many beds having side rails attached.
Two residents were prescribed and administered Seroquel for dementia-related diagnoses, contrary to facility policy that restricts antipsychotic use to specific, indicated conditions. An LPN reported the medication was used for behavioral issues, while the DON confirmed antipsychotics are not approved for dementia treatment. Despite this, multiple residents were receiving these medications for dementia.
The facility did not provide written notices of transfer to residents or their representatives when residents were sent to the hospital for acute medical issues. Staff interviews confirmed that written notices were not given, and the facility's policy did not include this requirement. Multiple staff members, including the ADON, interim DON, and an LPN, were unaware of the need to provide such notices, and a review of records showed no evidence of compliance.
A resident with moderate cognitive impairment, an indwelling urinary catheter, and multiple diagnoses did not have any documentation of routine catheter care in the clinical record over several months. Although the resident reported receiving frequent catheter care, facility leadership confirmed that without documentation, completion of care could not be verified.
Two residents were not offered pneumonia immunizations as required, despite physician orders, due to the facility lacking a policy and not consistently offering the vaccine. Both the infection preventionist and DON confirmed the absence of a policy and inconsistent practice.
A resident with severe cognitive impairment and multiple diagnoses did not receive scheduled laboratory tests as ordered by the physician. Review of records and staff interviews confirmed that required labs were not completed for three consecutive scheduled periods, despite facility policy mandating timely processing and arrangement of such tests.
The facility failed to provide Advanced Beneficiary Notification (ABN) forms to three residents who were discharged from Medicare Part A Services but remained in the facility. The MDS coordinator was unaware of the requirement to provide ABNs in such cases.
The facility failed to ensure that residents were free from physical restraints not required for medical treatment. A CNA locked the wheelchairs of three residents with cognitive impairments, preventing them from moving freely. The DON confirmed that this action constituted a restraint, which was against the facility's policy.
The facility failed to ensure the accuracy of a resident's assessment, incorrectly listing pneumonia as a current diagnosis despite no recent or current treatment for it and a history of pneumonia dating back to 2017. The MDS coordinator confirmed the inaccuracy after review.
The facility failed to update the care plan for a resident with congestive heart failure, hypertension, and atrial fibrillation. The care plan did not reflect the healing of a stage two pressure ulcer or the resident's admission to hospice, despite a physician's order and acknowledgment from the MDS coordinator.
The facility failed to ensure the ice machine was clean, with black and pink substances observed on the deflector plate. A dietary aide confirmed the substances were mold and stated the machine had last been cleaned four weeks ago, with the ice company responsible for its cleaning.
Failure to Complete Comprehensive Care Plan Following Admission Assessment
Penalty
Summary
The facility failed to complete an initial comprehensive care plan within seven days of the admission MDS assessment for one resident. Facility policy titled "Care Planning-Interdisciplinary Team" dated 09/2013 required that a comprehensive care plan be developed within seven days of completion of the resident assessment (MDS). The admission assessment for Resident #1 was dated 02/10/26 and showed completion on 02/12/26, but review of the EMR revealed no comprehensive care plan for this resident. On 04/10/26, the facility provided an undated baseline care plan for Resident #1, but no comprehensive care plan was found in the EMR. During interviews on 04/10/26, the MDS coordinator stated they did not develop a comprehensive care plan for Resident #1, and the administrator confirmed that only a baseline care plan could be located and acknowledged awareness that a comprehensive care plan had not been completed. The administrator identified that 52 residents resided in the facility at the time of the survey, and the deficiency was identified for 1 of 7 sampled residents reviewed for comprehensive care plans.
Repeated Elopements and Self-Harm Due to Ineffective Supervision and Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement and self-harm for a resident identified as high risk for wandering and elopement. The resident was cognitively intact on admission, with a BIMS score of 14, but had diagnoses including Huntington’s Disease, anxiety, depression, delusions, and hallucinations, and a history of falls prior to admission. The admission assessment documented that the resident wandered one to three days per week and that this wandering placed them at significant risk of getting to a potentially dangerous place. A care plan dated at admission identified the resident as at risk for elopement and wandering related to hallucinations, with interventions focused on distraction, identifying wandering patterns, monitoring for fatigue and weight loss, and providing structured activities and reorientation strategies. A wandering risk evaluation completed shortly after admission scored the resident at high risk for wandering. Despite this, the resident repeatedly eloped from the facility. On one occasion in October, the resident left the facility without notice, crossed the parking lot, and fell in an adjacent field before being returned with assistance from local authorities; the facility’s intervention was to initiate visual checks every 15 minutes. In early November, staff documented escalating psychotic behavior, including the resident talking to themselves, insisting on contacting the FBI, and making threats toward staff and other residents. During this episode, the resident pulled a phone line from the wall and then ran out the front door, leading staff to call 911 and local authorities to locate the resident at a hotel. The facility later documented that the resident was involuntarily admitted to a hospital for psychiatric evaluation and treatment and subsequently returned to the facility. Following the resident’s return, elopements continued. In mid-January, staff were unable to locate the resident in the facility; family located and returned the resident, and documentation showed the resident had intentionally burned the back of their hand with a cigarette lighter while away because they did not want to come back. The state reportable incident for that date documented the elopement and the use of every 15-minute checks but did not document the burn injury, which was later noted on a weekly skin observation as multiple blister sites from self-inflicted burns. In early February, the resident again left the facility after being denied early medication, walking out the front door after announcing they would leave; local authorities later found the resident at a residence identified as a known drug house. The resident eloped again the following day after being denied unscheduled medication and a supervised walk; staff did not realize the resident was missing for approximately 30 minutes, and family found the resident about a mile away at a local business. For each of these elopements, the facility’s intervention remained every 15-minute visual checks, and no new interventions were added to the care plan. Staff interviews further described the resident as independent but needing supervision, with a history of illicit drug use and drug-seeking behaviors, and noted that behavioral triggers often involved not receiving medications when desired. An LPN reported that walking outside with the resident or engaging them in music sometimes helped, and that if the resident became too upset, they would call an ambulance or leave the facility. The DON acknowledged that the facility did not investigate the elopements to determine root causes, although camera footage was reviewed to see when and how the resident exited. The DON noted that on one occasion the resident watched activity around a back door before exiting, and that staff reports of when the resident was last seen were inaccurate compared to camera footage. The DON also stated that the intervention of every 15-minute checks did not appear to be effective, yet this intervention was repeatedly used as the primary response without modification of the care plan, contributing to the failure to provide adequate supervision to prevent further elopement and self-harm.
Removal Plan
- Place the identified resident on continuous 1:1 supervision (line-of-sight monitoring).
- Ensure the assigned 1:1 staff maintains visual contact with the resident at all times.
- Provide uninterrupted 1:1 coverage by relieving the sitter with a designated backup staff member during all breaks.
- Require the charge nurse to assign a backup sitter at the beginning of each shift.
- Document backup staff on the assignment sheet.
- Prohibit breaks without a confirmed face-to-face handoff between sitter and backup.
- Require the 1:1 staff to document every 15 minutes that they have eyes on the resident and the resident’s location on the 15-minute checks sheet.
- Require completed 15-minute check sheets to be turned in to the DON for approval.
- Assign a secondary staff member each shift as designated break coverage to ensure no lapse in supervision.
- Verify door alarm functionality immediately (maintenance and nursing staff).
- Update the resident’s care plan to reflect 1:1 supervision, high elopement risk status, and supervision requirements.
- Complete wandering risk assessments for all residents in the facility.
- Educate all staff on elopement risk, what to do in case of elopement (stay with resident, call 911, ensure safe return, notify charge nurse; charge nurse to notify physician/administrator/DON/family), and 1:1 sitter responsibilities.
- Do not allow staff who missed the education to clock in/work until education is provided and understood.
- Maintain attendance sheets in the education file.
- Review and update the resident’s comprehensive care plan via the interdisciplinary team to include high elopement risk identification, continuous 1:1 line-of-sight supervision, designated break relief protocol with face-to-face handoff, redirection techniques, monitoring frequency and documentation requirements, and conducting an investigation and root cause analysis after any additional exit-seeking behavior to update the care plan.
Missed Quarterly MDS Assessment Due to Interim Staff Oversight
Penalty
Summary
The facility failed to complete a required quarterly MDS assessment for one resident, resulting in the resident not having an updated assessment within three months of the admission assessment. Record review showed an admission assessment dated 09/28/25, an annual assessment, a discharge with return anticipated dated 11/06/25, and an entry dated 11/19/25 for this resident, but no subsequent quarterly assessment was documented. During interview, an LPN who was one of two interim nurses assigned to perform MDS assessments and care plans while the MDS coordinator was on leave stated they were not aware that this resident’s quarterly MDS was due. The DON confirmed that the quarterly assessment for this resident was late because the interim MDS nurse did not perform the required assessment duties.
Failure to Revise Elopement Care Plan After Multiple Incidents
Penalty
Summary
The facility failed to update and revise the care plan for elopement for one resident after multiple elopement incidents, despite regulatory requirements that care plans be developed, reviewed, and revised by a team of health professionals. Record review showed the resident’s elopement care plan, initiated on 09/28/25, identified a concern for elopement but contained no evidence of review or updates following elopement events on 10/15/25, 11/06/25, 01/16/26, 02/08/26, or 02/09/26. On 02/19/26, an LPN confirmed that the elopement interventions had not been updated since the care plan was first developed. On 02/23/26, another LPN reported believing that the DON had recently updated the elopement care plan, which was not the case. Later that same day, the DON stated that the care plan for this resident had not been updated because the interim MDS nurse had not performed their duties. These findings demonstrate that, although the resident had repeated elopement episodes documented in the record, the care plan remained unchanged from its original version, and staff interviews confirmed that no revisions were made in response to the subsequent events.
Failure to Conduct Routine Bed Frame and Bed Rail Safety Inspections
Penalty
Summary
The facility failed to conduct routine safety inspections of bed frames and bed rails for three of four sampled residents reviewed for accident hazards. Observations showed that these residents were using beds with 1/8 sized side rails attached to the bed frames. When questioned, the maintenance staff member confirmed that no inspections of bed frames or side rails had been performed and that there were no records of such inspections. The maintenance staff also indicated a misunderstanding regarding what constituted a bed rail, as they did not consider the smaller side rails in use as bed rails. It was identified that 46 beds in the facility had side rails attached, but no inspection records were available.
Unnecessary Use of Antipsychotic Medications for Dementia Diagnoses
Penalty
Summary
The facility failed to ensure that residents were not prescribed antipsychotic medications for the medical diagnosis of dementia, as evidenced by the cases of two residents who were administered Seroquel for dementia-related diagnoses. One resident was prescribed Seroquel 50 mg twice daily for vascular dementia with behavioral disturbances, and received 47 doses over a one-month period. Another resident was prescribed Seroquel 12.5 mg daily for unspecified dementia with psychotic disturbance, receiving 26 doses in the same timeframe. The facility's policy states that antipsychotic medications should only be used when necessary to treat specific, indicated conditions. During interviews, an LPN stated that Seroquel was being used for behaviors such as hitting or refusing care, and confirmed that the documented diagnosis being treated was dementia. The LPN was not aware if Seroquel was approved for the treatment of dementia. The DON acknowledged that antipsychotic medications are not approved for the treatment of dementia and indicated a preference for discontinuing their use, stating that such medications should only be used for specific problems like delusions. Despite this, the facility had seven residents prescribed antipsychotic medications, with the two sampled residents receiving them for dementia diagnoses.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide written notices of transfer to residents and their representatives when residents were transferred to a hospital. Record review and staff interviews revealed that three residents who were hospitalized for various acute medical conditions, including tremors and unresponsiveness, abnormal heart rate with difficulty breathing, and abnormal CO2 levels, did not receive the required written notification of transfer. The facility's policy on emergency transfer or discharge did not include the requirement to provide such written notice prior to transfer. Interviews with the ADON, interim DON, and an LPN confirmed that written notices of transfer were not given to any residents transferred to the hospital, and staff were unaware of the regulatory requirement to do so. A review of the electronic medical records for the affected residents showed no evidence of written transfer notices being provided. The ADON stated that 54 residents had been transferred to a hospital during the review period, and none had received the required written notice.
Failure to Document Catheter Care in Medical Record
Penalty
Summary
The facility failed to ensure that routine catheter care was documented in the clinical record for one resident with an indwelling urinary catheter. According to the facility's undated Catheter Care, Urinary policy, the date, time, and name and title of the individual providing catheter care should be recorded in the resident's medical record. A quarterly assessment showed the resident had moderate cognitive impairment, an indwelling urinary catheter, and diagnoses including acute kidney failure and diabetes mellitus. A review of the resident's medical record for three consecutive months revealed no documentation of catheter care. The resident reported receiving frequent catheter care, but both the ADON and DON confirmed that if catheter care was not documented, it could not be verified as completed.
Failure to Offer Pneumonia Immunizations Due to Lack of Policy
Penalty
Summary
The facility failed to ensure that residents were offered pneumonia immunizations as required, as evidenced by the review of medical records for two of five sampled residents. Physician orders for both residents indicated they were to be offered pneumonia immunizations if indicated, but their medical records did not show that the immunizations had been received or offered. During interviews, the infection preventionist confirmed that the facility did not have a policy regarding pneumonia immunizations and had not been offering them consistently to residents. The DON also acknowledged the absence of a policy and the lack of consistent offering of pneumonia immunizations to residents.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by a physician were completed for a resident with dementia and osteoarthritis. According to the resident's admission record and quarterly assessment, the resident had severe cognitive impairment and was to receive specific lab tests every six months as ordered by the physician. Review of the health record showed that the last lab results were from January 2024, with no evidence that the required labs for July 2024, January 2025, and July 2025 were completed. Interviews with staff confirmed that these lab tests had not been performed, despite the facility's policy requiring staff to process and arrange for ordered diagnostic and lab testing.
Failure to Provide Advanced Beneficiary Notifications
Penalty
Summary
The facility failed to ensure Advanced Beneficiary Notification (ABN) forms were provided to three residents who were reviewed for ABNs. Resident #9 was admitted to Part A Skilled Services and remained in the facility after being discharged from Medicare Part A Services without receiving an ABN. Similarly, Resident #11 and Resident #21 were also discharged from Medicare Part A Services and continued to stay in the facility without being provided ABNs. The MDS coordinator admitted to not being aware that ABNs were required when residents were discharged from Medicare Part A Services but remained in the facility.
Failure to Ensure Residents are Free from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints that were not required to treat a medical symptom. This deficiency was observed in four residents who had their wheelchairs locked by a CNA, preventing them from moving freely. The facility's policy on physical restraints states that no resident should be restrained for convenience, yet the CNA admitted to locking the wheelchairs to prevent the residents from pushing away, acknowledging that the residents were unable to unlock the wheelchairs themselves. Resident #7, who had dementia and was moderately impaired in daily decision-making, Resident #13, who had dementia and was severely impaired in daily decision-making, and Resident #14, who had major depressive disorder and was severely impaired in daily decision-making, were all observed with their wheelchairs locked. The DON confirmed that locking the wheelchairs constituted a restraint, which was against the facility's policy. This action restricted the residents' freedom of movement without a medical necessity, leading to the deficiency noted in the report.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure the accuracy of assessments for a resident diagnosed with cerebral infarction, reduced mobility, and hypertension. A quarterly assessment inaccurately listed pneumonia as a current diagnosis for the resident. However, a review of physician orders and the resident's clinical record revealed no recent or current antibiotics prescribed for pneumonia, and the resident's history of pneumonia dated back to 2017. The MDS coordinator, upon review, could not locate any information supporting the pneumonia diagnosis in the quarterly assessment, confirming the inaccuracy of the MDS.
Failure to Update Care Plans
Penalty
Summary
The facility failed to ensure care plans were updated for a resident who was admitted with diagnoses including congestive heart failure, hypertension, and atrial fibrillation. The care plan, revised on 01/23/24, documented a stage two pressure ulcer to the coccyx but did not document that the ulcer had healed. Additionally, the care plan did not reflect the resident's admission to hospice, despite a physician's order dated 01/26/24 to admit the resident to hospice. On 04/11/24, the MDS coordinator acknowledged that the care plan had not been updated to reflect the healed wound and the hospice admission, stating they had forgotten to make these updates.
Ice Machine Cleanliness Deficiency
Penalty
Summary
The facility failed to ensure the ice machine was clean. An untitled and undated policy indicated that ice should be produced, stored, and dispensed in a manner to avoid contamination, and the ice dispenser should be cleaned and sanitized at least monthly or as needed. An invoice dated 03/08/24 documented that only the bin sensor was cleaned, with no other cleaning of the machine recorded. On 04/09/24 at 11:25 a.m., the ice machine was observed to have black and pink substances on the deflector plate in the bin. Dietary Aide #1 confirmed that the ice machine had last been cleaned four weeks ago, identified the substances as mold, and stated that the ice company was responsible for cleaning the machine. The aide also mentioned that the ice machine should be shut down and cleaned immediately.
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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) |
|---|---|---|---|---|
| Aspen Health And Rehab | 1 mi | ★★★★★ | 2 | 0 |
| Broken Arrow Nursing Home, Inc | 1.3 mi | ★★★★★ | 0 | 0 |
| Cedarcrest Care Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Senior Suites Healthcare | 2.3 mi | ★★★★★ | 15 | 0 |
| Forest Hills Care And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
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