SeniorHomeViolations
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Village Health Care Center Inspection Report, Violations & Safety Grade (Broken Arrow, Oklahoma)

1709 South Main, Broken Arrow, Oklahoma 74012

Phone: 9182512626

CMS Overall:1/5

Overview & Bed Count

Certified Beds
90
Avg Residents/Day
48.6
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Tulsa
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall1/5
Health1/5
Staffing1/5
Quality1/5

Nurse Staffing Check

MetricThis FacilityOklahoma AvgDifference
RN Hours per Resident per Day0.000.34-0.34
Total Nurse Hours per Resident per Day0.003.82-3.82
CMS Staffing Rating1/52.7/5-
Nursing Staff TurnoverN/A55.4%-

Health Citation History

38 health citations on record

DateCategoryDescriptionSeverity
2026-04-10Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2026-02-24Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J – Immediate Jeopardy
2026-02-24Resident Assessment and Care Planning DeficienciesAssure that each resident’s assessment is updated at least once every 3 months.D – Moderate Harm Potential
2026-02-24Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2025-08-28Environmental DeficienciesRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.F – Moderate Harm Potential
2025-08-28Freedom from Abuse, Neglect, and Exploitation DeficienciesPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.E – Moderate Harm Potential
2025-08-28Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.E – Moderate Harm Potential
2025-08-28Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.E – Moderate Harm Potential
2025-08-28Infection Control DeficienciesDevelop and implement policies and procedures for flu and pneumonia vaccinations.E – Moderate Harm Potential
2025-08-28Administration DeficienciesProvide timely, quality laboratory services/tests to meet the needs of residents.D – Moderate Harm Potential
2024-04-11Resident Rights DeficienciesGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.D – Moderate Harm Potential
2024-04-11Freedom from Abuse, Neglect, and Exploitation DeficienciesEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.D – Moderate Harm Potential
2024-04-11Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2024-04-11Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2024-04-11Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.D – Moderate Harm Potential
2023-02-24Resident Rights DeficienciesHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.E – Moderate Harm Potential
2023-02-24Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.E – Moderate Harm Potential
2023-02-24Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E – Moderate Harm Potential
2023-02-24Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.E – Moderate Harm Potential
2023-02-24Quality of Life and Care DeficienciesProvide enough food/fluids to maintain a resident's health.E – Moderate Harm Potential
2023-02-24Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.E – Moderate Harm Potential
2023-02-24Quality of Life and Care DeficienciesTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.E – Moderate Harm Potential
2023-02-24Nursing and Physician Services DeficienciesHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.E – Moderate Harm Potential
2023-02-24Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.E – Moderate Harm Potential
2023-02-24Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.E – Moderate Harm Potential
2023-02-24Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.E – Moderate Harm Potential
2023-02-24Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.E – Moderate Harm Potential
2023-02-24Administration DeficienciesSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.E – Moderate Harm Potential
2023-02-24Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2023-02-24Infection Control DeficienciesEnsure staff are vaccinated for COVID-19E – Moderate Harm Potential
2023-02-24Resident Rights DeficienciesHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.D – Moderate Harm Potential
2023-02-24Resident Rights DeficienciesNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.D – Moderate Harm Potential
2023-02-24Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.D – Moderate Harm Potential
2023-02-24Resident Assessment and Care Planning DeficienciesAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.D – Moderate Harm Potential
2023-02-24Resident Assessment and Care Planning DeficienciesCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedD – Moderate Harm Potential
2023-02-24Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2023-02-24Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.D – Moderate Harm Potential
2023-02-24Environmental DeficienciesRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.D – Moderate Harm Potential

Fire Safety Citation History

9 fire safety citations on record

DateCategoryDescriptionSeverity
2024-04-11Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).F – Moderate Harm Potential
2024-04-11Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.F – Moderate Harm Potential
2024-04-11Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.C – Minimal Harm Potential
2023-02-24Smoke DeficienciesProvide properly protected cooking facilities.E – Moderate Harm Potential
2023-02-24Smoke DeficienciesProperly provide smoke detection systems in areas open to corridors.E – Moderate Harm Potential
2019-08-21Emergency Preparedness DeficienciesEstablish emergency prep training and testing.F – Moderate Harm Potential
2019-08-21Emergency Preparedness DeficienciesEstablish an Emergency Preparedness Program (EP).E – Moderate Harm Potential
2019-08-21Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2019-08-21Smoke DeficienciesEnsure that corridors are separated from use areas by walls constructed to limit the passage of smoke.E – Moderate Harm Potential

Total Penalties & Fines

$28,744
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2026-02-24Fine$28,744-

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