Cycle 1
Health 2024-12-23 · Fire 2024-12-23
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Broken Arrow, OK
Franciscan Villa
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
17110 East 51st Street, Broken Arrow, OK
(918) 355-1596
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Diakonos Group
Operator or chain grouping
Approved since
2008-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.12
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.00
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.14
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
916
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0171
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.52
Baseline 23.29% · Performance 18.89% · Measure score 6.52 · Achievement 5.47 · Improvement 6.52
Healthcare-associated infections
9.11
Baseline 7.71% · Performance 5.11% · Measure score 9.11 · Achievement 9.11 · Improvement 9
Total nurse turnover
3.09
Baseline 75.00% · Performance 57.00% · Measure score 3.09 · Achievement 1.63 · Improvement 3.09
Adjusted total nurse staffing
6.13
Baseline 5.91 hours · Performance 4.82 hours · Measure score 6.13 · Achievement 6.13 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.97% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 223 · Observed rate 13.45% · Lower 95% interval 8.5% |
| Discharge to community | 49.46% |
50.57%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 214 · Observed rate 42.52% · Lower 95% interval 42.5% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.86% |
95.27%
2.6 pts better
|
Numerator 137 · Denominator 140 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 140 |
| Discharge self-care score | 37.61% |
53.69%
16.1 pts worse
|
Numerator 41 · Denominator 109 |
| Discharge mobility score | 33.03% |
50.94%
17.9 pts worse
|
Numerator 36 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 5 · Denominator 140 · Adjusted rate 3.32% |
| Healthcare-associated infections requiring hospitalization | 5.11% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 2.4% · Lower 95% interval 2.87% |
| Staff COVID-19 vaccination coverage | 0.64% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 157 |
| Staff flu vaccination coverage | 27.54% |
42%
14.5 pts worse
|
Numerator 38 · Denominator 138 |
| Discharge function score | 44.95% |
56.45%
11.5 pts worse
|
Numerator 49 · Denominator 109 |
| Transfer of health information to provider | 95.24% |
95.95%
0.7 pts worse
|
Numerator 100 · Denominator 105 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.39% |
25.2%
7.8 pts worse
|
Numerator 12 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.9
0.6 pts better
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.3%
9.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.6%
4.2 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
4.5%
1.4 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.8% · Q3 2.7% · Q4 2.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
3.3%
3.1 pts worse
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.8% · Q3 4.7% · Q4 7.3% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.6%
3.6 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.2% |
25.3%
3.9 pts worse
|
19.6%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 30.2% · Q3 29.2% · Q4 30.0% · 4Q avg 29.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
18.6%
9.7 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 8.0% · Q3 7.5% · Q4 5.1% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.6% |
15.5%
0.9 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 14.2% · Q3 7.5% · Q4 19.1% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
14.1%
0.5 pts worse
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 15.0% · Q3 9.4% · Q4 16.9% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.1%
1.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.8%
0.7 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 6.8% · Q4 2.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
17.8%
3.4 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 12.8% · Q3 33.8% · Q4 21.9% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.1%
0.4 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.8% · Q3 4.7% · Q4 5.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
75.0%
21 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.4% · Q3 93.1% · Q4 92.6% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
17.1%
4 pts better
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 13.1% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.9%
1.7 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
74.0%
23.3 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
27.0%
5 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 22.6% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-20 · Fire 2022-07-20
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-22
F · Potential for more than minimal harm
2022-07-20
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-08-17
F · Potential for more than minimal harm
2022-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-10
F · Potential for more than minimal harm
2022-07-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-08-18
E · Potential for more than minimal harm
2022-07-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-08-18
E · Potential for more than minimal harm
2022-07-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-18
C · Minimal harm
2022-07-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-17
C · Minimal harm
2022-07-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-23
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-20
G · Actual harm
2022-07-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-20
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-17
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Broken Arrow Nursing Home, Inc
Broken Arrow, OK
3-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Cedarcrest Care Center
Broken Arrow, OK
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Aspen Health and Rehab
Broken Arrow, OK
1-star overall rating with 1-star inspections with abuse icon flag with $35,721 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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