Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
88 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 88
Deficiencies: 1
Date: Dec 23, 2024
Visit Reason
The inspection was conducted to assess the palatability, attractiveness, and safe temperature of food and drink served to residents at the facility.
Findings
The facility failed to provide palatable meals for three residents interviewed regarding food palatability. Observations included food served cold or barely warm, items served against resident dietary instructions, and stale bread. The dietary manager acknowledged the issues with bread preparation.
Deficiencies (1)
Failed to provide palatable meals for three residents regarding food palatability.
Report Facts
Residents who ate meals prepared in the kitchen: 88
Residents interviewed regarding food palatability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| dietary manager | Informed of food palatability observations and acknowledged bread was left to proof too long |
Inspection Report
Routine
Census: 88
Deficiencies: 2
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage and food palatability standards at the facility.
Findings
The facility failed to store medications within locked compartments on medication carts, with multiple observations of unlocked treatment carts. Additionally, the facility failed to provide palatable meals for three residents, with food served at inappropriate temperatures and some items tasting stale or bad.
Deficiencies (2)
Failed to store medications within locked compartments of a medication cart on one of three halls observed.
Failed to provide palatable meals for three residents, with food served cold or barely warm and some items tasting bad or stale.
Report Facts
Residents interviewed regarding food palatability: 3
Residents who ate meals prepared in the kitchen: 88
Medication carts and treatment carts observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Identified medication and treatment carts storing medications | |
| LPN #1 | Observed removing items from unlocked treatment cart and acknowledged it should be locked | |
| LPN #2 | Stated treatment cart should not be left unlocked | |
| Dietary Manager | Informed of food palatability observations and stated bread was left to proof too long |
Inspection Report
Renewal
Census: 50
Deficiencies: 4
Date: Oct 12, 2023
Visit Reason
A relicensure survey was conducted at the assisted living center from October 11 through October 12, 2023, to assess compliance with state regulations and licensing requirements.
Findings
The facility was found deficient in several areas including failure to have assessments signed by a registered nurse or physician for some residents, failure to develop care plans for certain residents, lack of annual fire safety inspections, and medication administration issues including failure to administer medications per physician orders and failure to assess self-administration of medications properly.
Deficiencies (4)
Failed to ensure assessments were reviewed and signed by a registered nurse or physician for two of nine residents reviewed.
Failed to develop a care plan for two of nine residents reviewed.
Failed to ensure fire safety inspections were completed annually.
Failed to administer medications per physician orders and failed to identify and assess for self-administration of medications for one of four sampled residents.
Report Facts
Residents present: 50
Deficiencies cited: 4
Months behind fire inspection: 8
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 20, 2022
Visit Reason
The inspection was conducted as part of a regulatory compliance survey to assess the facility's adherence to healthcare regulations including resident assessments, catheter care, dietary interventions, medication management, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to identify and address significant weight loss in residents, lack of physician orders and documentation for indwelling urinary catheter use, failure to implement dietary recommendations for weight loss, inadequate documentation of pharmacy recommendation rationales, unsanitary kitchen conditions, and improper infection control practices during wound care.
Deficiencies (6)
Failed to identify significant weight loss for one resident (#62) during comprehensive assessments.
Failed to ensure catheter care was documented, physician order obtained, and diagnosis documented for indwelling urinary catheter use for one resident (#30).
Failed to implement dietary recommendations for interventions in weight loss for one resident (#62).
Failed to ensure a clinical rationale was provided when pharmacy recommendations were declined for two residents (#8 and #25).
Failed to maintain sanitary conditions in the kitchen including ice machine and microwaves.
Failed to ensure infection control was maintained during wound care for one resident (#57).
Report Facts
Residents with indwelling urinary catheter: 5
Residents reviewed for indwelling urinary catheter use: 4
Residents reviewed for significant weight loss: 4
Residents reviewed for unnecessary medications: 5
Residents who received medications: 89
Weight loss percentage: 20
Weight loss percentage: 11
Weight loss percentage: 10.8
Weight loss percentage: 14
Weight loss percentage: 18.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed providing wound care with improper infection control |
| Director of Nursing | Director of Nursing | Interviewed regarding weight loss identification, catheter care, pharmacy recommendations, and dietary supplements |
| Assistant Dietary Manager | Assistant Dietary Manager | Interviewed regarding kitchen sanitation and dietary interventions |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding catheter care frequency and documentation |
| LPN #1 | Licensed Practical Nurse | Reported to have called resident's hospice regarding catheter use |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Oct 15, 2021
Visit Reason
A complaint survey was conducted to investigate complaint #OK00057771 regarding the center's failure to assess a resident who had a change in condition.
Complaint Details
The allegation that the center failed to assess a resident who had a change in condition was unsubstantiated (US).
Findings
The investigation found that the allegation was unsubstantiated. However, a deficiency was cited for failure to ensure staff washed their hands between contact with residents and residents' belongings during a meal pass, posing an infection control risk.
Deficiencies (1)
Failure to ensure staff washed their hands between contact with residents and residents' belongings during one meal pass observed for infection control.
Report Facts
Residents present: 46
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billie Seeman | RN, CHFS | Signed the complaint investigation report |
| Dinah Donley | Administrator-Executive Director | Named in the report as facility administrator |
| Tempal Killman | Administrative Assistant II | Signed acceptance letter for plan of correction |
| Lisa Calvin | Enforcement Analyst | Signed letter regarding offsite complaint revisit |
Inspection Report
Renewal
Capacity: 181
Deficiencies: 0
Date: Nov 20, 2019
Visit Reason
The document is a renewal license issued to Franciscan Villa, LLC to conduct and maintain a Continuum of Care Facility.
Findings
The license certifies the facility's capacity for 110 nursing facility beds and 71 assisted living beds, with no adult day care or specialized Alzheimer's beds.
Report Facts
Maximum Nursing Facility Beds: 110
Maximum Assisted Living Beds: 71
Inspection Report
Renewal
Census: 41
Deficiencies: 5
Date: Jul 10, 2019
Visit Reason
A re-licensure survey was conducted from July 8 through July 10, 2019, to assess compliance with state regulations for the assisted living center.
Findings
Multiple deficiencies were cited including failure to complete annual performance reviews for nurse aides, incomplete admission and comprehensive assessments for residents, lack of first aid training documentation for direct care staff, and incomplete medication administration records.
Deficiencies (5)
Failure to ensure a performance review was completed annually for 3 of 4 sampled long term care aides employed for at least one year.
Failure to complete an admission assessment within 30 days of admission for 1 of 2 sampled residents.
Failure to complete comprehensive assessments annually or after significant change for 3 of 6 sampled residents.
Failure to ensure 2 of 7 sampled direct care staff were trained in first aid and cardiopulmonary resuscitation.
Failure to maintain accurate medication administration records including identity and signature of persons administering medications for 4 of 4 sampled residents.
Report Facts
Resident census: 41
Survey dates: 3
Number of sampled long term care aides: 4
Number of sampled residents for assessments: 6
Number of sampled residents for admission assessment: 2
Number of sampled direct care staff: 7
Number of sampled residents for medication records: 4
Inspection Report
Renewal
Capacity: 181
Deficiencies: 0
Date: Nov 20, 2018
Visit Reason
This document is a renewal license certifying Franciscan Villa, LLC to conduct and maintain a Continuum of Care Facility.
Findings
The license certifies the facility's capacity and compliance with state regulations for renewal purposes.
Report Facts
Nursing Facility Beds: 110
Assisted Living Beds: 71
Adult Day Care Participants: 0
Specialized Facility for Alzheimer's Residents Beds: 0
Inspection Report
Renewal
Capacity: 181
Deficiencies: 0
Date: 12 21 2020 LICENSE 106019
Visit Reason
This document serves as a license renewal for Franciscan Villa, LLC, a Continuum of Care Facility, authorizing the facility to maintain nursing and assisted living beds.
Findings
The license certifies the facility's compliance with state regulations to operate with a maximum capacity of 110 nursing facility beds and 71 assisted living beds.
Report Facts
Maximum Nursing Facility Beds: 110
Maximum Assisted Living Beds: 71
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