Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Franciscan Villa
Broken Arrow, OK · 110 certified beds · Last Life Safety survey December 23, 2024
CMS Certification Number 375525 · first certified July 2008
Ownership
Independently operated (no chain recorded by CMS) · For profit - Individual
- New ownershipOwnership changed June 1, 2025 (change of ownership)from FRANCISCAN VILLA LLC
Position within OK
9 citations — more than 58% of the 283 certified nursing homes in OK. Compared within OK rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2026 to April 2026), and past the point by which nine in ten OK facilities have been surveyed. This facility’s last Life Safety survey was December 2024. Facilities in OK are typically surveyed 14–16 months after the last one (median 15), measured over 277 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 9 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in OK, and nationally. Surveyors differ markedly between states, so the OK figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 9 |
| Median facility in OK | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 20, 2022 | 8 |
| September 21, 2023 | 0 |
| December 23, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-12-23 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 1 | 2022-07-20 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2022-07-20 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2022-07-20 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2022-07-20 |
| K-0222 | 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. | 1 | 2022-07-20 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2022-07-20 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2022-07-20 |
What the citations cover
- Smoke Deficiencies 5
- Egress Deficiencies 2
- Miscellaneous Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 23, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 22, 2025) |
July 20, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (August 18, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 17, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 17, 2022) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (August 17, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 10, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 18, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 17, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 18, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.