Cycle 1
Health 2025-08-28 · Fire 2024-04-11
6 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Broken Arrow, OK
Village Health Care Center
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1709 South Main, Broken Arrow, OK
(918) 251-2626
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.22
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,598
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 80.00% · Performance 80.56% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.23
Baseline 3.90 hours · Performance 4 hours · Measure score 3.23 · Achievement 3.23 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.63% |
8.2%
5.6 pts worse
|
Numerator 1 · Denominator 38 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 11 · Denominator 66 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.1 |
2.9
2.2 pts worse
|
1.8
3.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.1 · Observed 4.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 9.9% |
90.3%
80.4 pts worse
|
93.4%
83.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 8.7% · Q3 8.2% · Q4 10.0% · 4Q avg 9.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
94.6%
2.3 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
4.5%
0.2 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 4.3% · Q3 4.1% · Q4 2.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
3.3%
4.8 pts worse
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 10.5% · Q3 11.1% · Q4 6.4% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
3.6%
5.7 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.3% · Q3 10.0% · Q4 6.5% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
25.3%
9.3 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 13.3% · Q3 12.9% · Q4 24.2% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
18.6%
5.4 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 10.7% · Q4 13.3% · 4Q avg 13.2% · 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 | 25.2% |
15.5%
9.7 pts worse
|
16.3%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
14.1%
3.3 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 20.7% · Q3 13.3% · Q4 3.1% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 11.2% |
2.1%
9.1 pts worse
|
1.0%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 16.7% · Q3 10.7% · Q4 7.2% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.8% |
2.8%
7 pts worse
|
1.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 13.3% · Q3 4.2% · Q4 6.2% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
17.8%
5.4 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 28.7% · Q3 23.4% · Q4 20.8% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.1%
1.3 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 6.0% · Q3 4.6% · Q4 2.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 5.1% |
75.0%
69.9 pts worse
|
81.7%
76.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2023-02-24
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-24 · Fire 2019-08-21
24 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-07
F · Potential for more than minimal harm
2024-04-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-07
C · Minimal harm
2024-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-12
E · Potential for more than minimal harm
2023-02-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-04-20
F · Potential for more than minimal harm
2019-08-21
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-21
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-21
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 2019-10-10
E · Potential for more than minimal harm
2019-08-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2019-10-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-28
F909 · Environmental Deficiencies
Health
Regularly 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.
Corrected 2025-10-24
E · Potential for more than minimal harm
2025-08-28
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-24
E · Potential for more than minimal harm
2025-08-28
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-24
E · Potential for more than minimal harm
2025-08-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-10-24
E · Potential for more than minimal harm
2025-08-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-08-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-10-24
D · Potential for more than minimal harm
2024-04-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-11
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 2024-06-07
D · Potential for more than minimal harm
2023-04-28
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-02-24
F578 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F700 · Quality of Life and Care Deficiencies
Health
Try 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.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F727 · Nursing and Physician Services Deficiencies
Health
Have 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.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
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 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-24
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-24
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-02-24
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-24
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-02-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-02-24
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 2023-04-20
D · Potential for more than minimal harm
2023-02-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-02-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-24
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 2023-04-20
D · Potential for more than minimal harm
2023-02-24
F909 · Environmental Deficiencies
Health
Regularly 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.
Corrected 2023-04-20
Penalties and ownership
What sits behind the stars
Ownership
Montgomery, Colton
5% Or Greater Direct Ownership Interest · Individual
Montgomery, Taralee
5% Or Greater Direct Ownership Interest · Individual
Montgomery, Colton
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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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
#2
Broken Arrow Nursing Home, Inc
Broken Arrow, OK
3-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
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
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