Deficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 50
Deficiencies: 4
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.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure assessments were reviewed and signed by a registered nurse or physician for two of nine residents reviewed. | SS=D |
| Failed to develop a care plan for two of nine residents reviewed. | SS=D |
| Failed to ensure fire safety inspections were completed annually. | SS=F |
| Failed to administer medications per physician orders and failed to identify and assess for self-administration of medications for one of four sampled residents. | SS=D |
Report Facts
Residents present: 50
Deficiencies cited: 4
Months behind fire inspection: 8
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
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.
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.
Complaint Details
The allegation that the center failed to assess a resident who had a change in condition was unsubstantiated (US).
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff washed their hands between contact with residents and residents' belongings during one meal pass observed for infection control. | SS=E |
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
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
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)
| Description |
|---|
| 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
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
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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