Baptist Village of Oklahoma City
9700 Mashburn Blvd, Oklahoma City, OK 73162 · Non profit - Corporation · 120 certified beds · (405) 721-2466 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $28,695 in federal fines (most recent 2025-10-01)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.4% | 13.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.0% | 3.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.6% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.3% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 4.7% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.4% | 13.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.7% | 25.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.5% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.2% | 17.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.6% | 17.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.2% | 74.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.5% | 27.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.8% | 16.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.87 | 2.31 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.18 | 2.96 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 578 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 248 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.2%CMS range 58.4–65.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.6%CMS range 10.0–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 68.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.3%CMS range 6.7–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 95.9 residents a day — about 80% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 4.21 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 5.29 hrs/resident/day on weekends vs 6.49 on weekdays — 18% thinner on weekends. RN hours go from 0.49 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 14 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-07-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
On 07/15/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to ensure the shower room door on the memory care unit closed and locked behind them to ensure residents were not able to enter the room. On 7/15/24, during initial tour, the shower room floor was wet and slippery, there was a hair dryer placed in the grab bar area and it was plugged it to the electrical outlet. There were greater than 10 bottles of shampoos, conditioners, alcohol based surface cleaner, and shaving cream covering over half of the shower bench. The cabinet in the shower room was unlocked, razors within reach. Staff stated the shower room door was supposed to close behind them automatically. On 07/15/24 at 4:47 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to the shower room door being unsecured on the memory care unit. On 07/15/24 at 4:55 p.m., the Administrator was notified of the IJ situation. On 07/16/24 at 7:19 a.m., an acceptable plan of removal was submitted to the Oklahoma State…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-10-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to protect 1 (#106) of 2 sampled residents reviewed for abuse. Resident #106 was physically abused by Certified Nurse Aide # 8 causing two red marks on their right leg that was tender to touch. This caused Resident #106 to be afraid of the CNA. The administrator identified 95 residents resided in the facility Findings: On 09/28/25 at 5:15 p.m., Resident #106 was observed being propelled in a wheelchair to the dining room located on the memory care unit for the evening meal. An abuse policy, dated February 20, 2024, read in part, Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. An undated face sheet for Resident #106 showed they had diagnoses of chronic obstructive pulmonary disease, Alzheimer's, hypertension, and depression, A quarterly MDS, with an assessment reference date of 09/08/25 for Resident #106, showed they had a BIMS score of 05…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-07-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to prevent a decrease in range of motion for one (#40) of one sampled resident reviewed for limited range of motion. The DON identified 101 residents resided in the facility. Findings: Resident #40 had diagnoses which included parkinsonism and pain. A nursing note, dated 02/18/24, documented Resident #40 had a fall and complained of pain to their right hand. An x-ray report, dated 02/19/24, documented acute fracture in the right proximal phalanx of the fourth finger with mild soft tissue swelling. A physician's order, dated 03/17/24, documented buddy tape 3-4 fingers for three weeks. A Provider office visit note, dated 04/03/24, documented a boutonniere deformity of the right ring finger and difficulty with extension. It documented Resident #40 was placed in a finger splint and consult placed for surgical evaluation. On 07/15/24 at 9:19 a.m., Resident #40 stated they fell in 02/24 and broke their ring finger. They stated they did not get therapy for the finger and did not see an ortho surgeon for two months. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-07-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to review medications for a gradual dose reduction for four (#14, 33, 40, and #41) of five sampled residents reviewed for unnecessary medications. The DON identified 14 residents were on psychotropics medications in the facility. Findings: The Baptist Village Communities Psychotropic Medication Policy and Procedure, dated 02/20/24, read in part, Residents who receive psychotropic medications will receive gradual dose reductions and behavioral interventions unless clinically contraindicated with the intention to decrease or discontinue the use of the psychotropic medication whenever safe and possible. 1. Resident #40 had diagnoses which included dementia and depression. A physician's order, dated 03/09/22, documented escitalopram 10 mg, give one tablet by mouth daily for depression. A physician's order, dated 03/12/23, documented trazodone 50 mg tablet, may give two 25 mg to equal 50 mg one time daily for depression. A review from 07/23 of Resident #40's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-10-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide safe resident transfers for 1 (#65) of 3 sampled residents reviewed for accidents. The administrator identified 95 resided in the facility.Findings: On 09/30/25 at 9:02 a.m., Resident #65 was observed to be transferred from the bed to the wheelchair. CNA #4, CNA #5, and CNA #6 were in the resident's room for the transfer. The bed was elevated, resident the repositioned from side to side with two-person max assist for personal care, peri-care and brief change. The head of bed was elevated to assist with transfer and positioning of resident. A gait belt was applied around resident, under resident chest area and upper body, it was loose fitting. During the transfer, Resident #65 was lifted under their arms for most of weight by CNA #5 and CNA #6, and the gait belt was used for positioning by CNA #4 into wheelchair. The pressure under the resident arms could cause undue stress to resident arms, under arm area and shoulders and was unsafe, as the resident center of gravity was below the staff lifting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure enhanced barrier precautions were utilized for two of two (#1 and #3) residents observed with indwelling devices. A Resident/Guest Suite List, dated 10/15/24, documented 96 residents were residing at the facility. Findings: 1. Resident #1 had diagnoses that included diabetes mellitus with peripheral angiopathy with gangrene. The initial MDS assessment, dated 09/17/24, documented Resident #1 was dependent upon staff for activities of daily living. They had a central line and were receiving antibiotics through it. 2. Resident #3 had diagnoses that included cystitis and bacteremia. The quarterly MDS assessment, dated 08/27/24, documented Resident #3 was dependent upon staff for activities of daily living. They had an indwelling catheter. On 10/15/24 at 1:51 p.m., these resident rooms were observed to not have signage indicating enhanced barrier protections were required and there were no PPE carts observed nearby. On 10/15/24 at 1:59 p.m., LPN #1 stated they did not know what enhanced barrier precautions were, but they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to prevent a CNA from physically restraining one resident (#4) of three sampled residents reviewed for abuse. A Resident/Guest Suite List, dated 10/15/24, documented 96 residents were residing at the facility and 30 of the residents were in memory care. Findings: An ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY policy, dated February 20, 2024, read in part, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Resident #4 had diagnoses which included Alzheimer's, anxiety, depression, and cognitive communication deficit. A quarterly assessment, dated 07/07/24, documented the resident was severely cognitively impaired, and had wandered throughout their environment 4-6 of the last 7 days. An Incident Report Form, dated 09/23/24, documented that after receiving an allegation of abuse, camera playback was viewed, and CNA #1 was seen grabbing Resident #4 several times by the right arm and shirt to pull them down…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-19 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review and interview the facility failed to ensure breakfast menu was posted. Findings: The DON reported 101 residents, resided in the facility. The facility's policy Menu Posting and Menu Substitution dated 1/24, read in part Menus are to be posted at least one week in advance or more if state regulation requires. Menus are to be posted at a height and in font (minimum 14 Font) that can be easily read by all residents. Menus should include all daily available for each meal. On 07/12/24 at 8:31 a.m., no breakfast menu was posted. On 07/16/24 at 2:08p.m. the Registered Dietician reported they were not sure if the menu was posted.
- Potential for harm · E2024-07-19 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility failed to notify residents they were allowed to have resident council without staff present. The facility's deficient practice interfered with the resident's right to hold group meetings privately. The DON identified 101 residents resided in the facility. Findings: A Resident Rights: Resident and Family Groups policy, dated 02/20/24, stated team members, visitors and other guests may only attend the meeting upon invitation. On 07/17/24 at 10:55 a.m., the nine residents in attendance stated they were unaware they were allowed to have a resident council meeting without staff present. The social service staff member stated the were unaware but would review the policy.
- Potential for harm · E2024-07-19 · tag F0574 — patternThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure the ombudsman's contact information was posted in view of residents. The facility's deficient practice interfered with the resident's rights to communicate and access the state's ombudsman office. The DON identified 101 residents resided in the facility. Findings: Review of the facility's policy titled Resident Rights provided by the Administrator revealed .resident's right to . communication with and access to people and services, both inside and outside the facility .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .exercise his or her rights without interference, coercion .from the facility communicate with outside agencies .state long-term care ombudsman . On 07/17/24 at 11:36 a.m., an interview with the nine resident council members in attendance revealed they were unaware of who the ombudsman was, what their purpose was, or where to find that information. On 07/17/24 at 11:43 a.m., an eight by ten document with the Ombudsman name was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-19 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview, the facility failed to provide mail delivery to residents on Saturdays. The DON identified 101 residents resided in the facility. Findings: On 07/17/24 at 11:22 a.m., nine members of resident council stated the mail did not get distributed on the weekends. On 07/17/24 at 11:24 a.m., the social services staff stated mail gets delivered Saturdays but does not get passed out until Monday.
- Potential for harm · E2024-07-19 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure survey results were readily accessible/available to residents and visitors. The DON identified 101 residents resided in the facility. Findings: On 07/17/24 at 11:28 a.m., the nine resident council members stated they did not know where the state inspection book was. On 07/17/24 at 11:43 a.m., a sign was observed posted on the information board on the long-term care halls. The sign documented that survey results could be found at the front desk. There was no sign or mention of the survey results by the skilled halls.
- Potential for harm · E2024-07-19 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure residents and resident representatives were able to file a grievance form anonymously and post information regarding the name of the grievance official. The DON identified 101 residents resided in the facility. Findings: A Grievance Policy and Procedure, dated 02/2024, read in part the health center will provide a mechanism for filing a grievance/complaint without fear of retaliation .will provide residents, resident representatives and others information about the mechanisms and procedure to file a grievance; provide a designated individual to oversee the grievance process . On 07/17/24 at 11:10 a.m., the resident council members stated they did not know how to file a grievance, but that staff usually take care of their issues. On 07/17/24 at 11:22 a.m., the social services staff stated they were not positive who the grievance official was.
- Potential for harm · E2024-07-19 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide care in a timely manner to a resident with a fractured finger for one (#40) of three sampled residents reviewed for falls. The DON identified 101 residents resided in the facility. Findings: Resident #40 had diagnoses which included parkinsonism and pain. A nursing note, dated 02/18/24, documented Resident #40 had a fall and complained of pain to their right hand. An x-ray report, dated 02/19/24, documented acute fracture in the right proximal phalanx of the fourth finger with mild soft tissue swelling. A physician's order, dated 02/19/24, documented ice pack, four times daily for 14 days. Apply ice pack to right hand for 20 minutes max. A physician's order, dated 02/20/24, documented appointment ortho hand specialty referral, send x-ray result. Resident #40 was not seen by any provider until 03/17/24. A physician's order, dated 03/17/24, documented buddy tape 3-4 fingers for three weeks. Resident #40 was first seen for the ortho consult on 04/03/24. On 07/15/24 at 9:19 a.m., Resident #40 stated they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · E2024-07-19 · tag F0700 — patternTry 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the use of bed rails, an order and consent had been obtained prior to installation for two (#4 and #19) of two sampled residents reviewed for bed rails. The DON identified 13 residents who used bedrails in the facility. Findings: The BAPTIST VILLAGE COMMUNITIES BED RAIL POLICY AND PROCEDURE dated 02/20/24, read in part, completion of individual bed rail evaluation. The policy also read, .obtain informed consent from resident and/or resident representative .obtain physician order for medical symptoms evaluating the need for bed rail use. 1. Resident #4 had diagnoses which included fracture of right lower leg and need for assistance with personal care. Resident #4's quarterly resident assessment, dated 06/18/24, documented Resident #4 required extensive assistance with transfers. On 07/17/24 at 7:45 a.m., Resident #4 was observed in bed with two rails up on each side of the head of the bed. There was no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure: a. food items were labeled, dated and stored according to facility policy; b. proper food handling practices were followed to prevent the outbreak of foodborne illness; c. that staff changed gloves between task and according to facility policy; d. proper sanitization pratices or safety of the residents according to facility policy; e. hot food temperatures were documented according to facility policy. Findings: The DON reported 101 residents resided in the facility. a. The facility's policy Food and Supply Storage revised 1/24, read in part Cover, label and date unused portions and open packages. On 07/15/24 at 7:11 a.m., Dietary Aide #1 reported that all food items should be dated, labeled and stored. On 07/15/24 at 7:12 a.m., Dietary Aide #1 reported the tater tots, chicken tenders and bread should be dated, labeled and stored. On 07/12/24 at 7:18 a.m., Dietary Aide #1 reported it was bowl of sausages on the counter uncovered. b. The facility's policy Food Handling Guidelines undated, read in part…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-19 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure call devices were accessible to residents for two (#17 and #58) of 28 resident observed for call lights in the memory care unit. The DON identified 101 residents resided in the facility. Findings: A Call Light Answering Policy and Procedure, dated 02/20/24, read in part, BVC recognizes that residents may call for assistance frequently. It is the responsibility of the team to answer the call for service. 1. Resident #37 admitted on [DATE] with diagnoses which included dementia and heart failure. A quarterly assessment, dated 04/16/24, documented the resident was dependent on staff for assistance with their ADLs. On 07/15/24 at 7:25 a.m.,the call light cord was observed hanging over the head of the bed. The call light was not accessible to Resident #37 2. Resident #58 admitted on [DATE] with diagnoses which included diastolic (congestive) heart failure and Alzheimer's disease. A quarterly assessment, dated 06/06/24, documented the resident required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to promote resident dignity by staff standing over a resident while assisting them to eat. The DON identified 101 residents resided in the facility. Findings: Resident #76 admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease. A quarterly assessment, dated 04/04/24, documented the resident's cognition was severly impaired and they required supervision or touching assistance with eating. On 07/15/24 at 8:08 a.m., LPN #1 pulled a chair over to a table near the TV in the dining area. LPN #1 began assisting Resident #76 with his meal. LPN #1 was standing while they assisted Resident #76 with their meal. On 07/15/24 at 8:23 a.m., LPN #1 continued to assist Resident #76 with their meal. LPN #1 continued to stand while assisting. 07/15/24 at 9:09 a.m., LPN #1 stated they were standing while assisting Resident #76 with their meal. They stated that was not the policy, per policy staff should be seated when assisting residents with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order and an assessment to self-administer medications for one (#1) of one sampled resident reviewed for self-administration of medications. The DON identified 101 residents resided in the facility. Findings: The Baptist Village Communities Self-Administration of Medications policy, dated 02/20/24, read in part, .The interdisciplinary team will assess the resident to determine if self-administration of medication is clinically appropriate, safe, and feasible. The policy also read, .A physician's order will be obtained and recorded in the chart. The order also will include which specific medications can be kept at the beside. On 07/15/24 at 8:34 a.m., A bottle of saline nasal spray was observed on Resident #1's nightstand. The Resident stated they self-administered the nasal spray at night. There was no documentation the resident had physician orders to self-administer medications or for the use of the nasal spray. On 07/18/24 at 11:56 a.m., LPN #2 stated Resident #1 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately complete a quarterly assessment for one (#45) of 21 sampled residents for accurate MDS assessments. The DON identified 101 residents resided in the facility. Findings: The Facility's Comprehensive Care Plan Policy and Procedure, dated 02/20/24, documented the facility must conduct initially and periodically a comprehensive, accurate, standardized assessment. Resident #45 admitted to the facility on [DATE] with diagnoses which included parkinsonism and psychotic disorder with hallucinations. A physician's order, dated 02/19/24, documented to administer 34 mg of Nuplazid (antipsychotic medication) at bedtime. An admission assessment, dated 03/01/24, document Resident #45 had not received antipsychotic medications. The Feburary MAR documented the Nuplazid had been administered each day of the look back period. On 07/19/24 at 11:11 a.m., MDS Coordinator #1 stated the admission assessment did not document Resident #45 had taken an antipsychotic.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a care plan was revised to include the use of bed rails for two (#4 and #19) of two sampled residents whose care plans were reviewed for bed rail use. The DON identified 101 residents resided in the facility. Findings: The Baptist Village Communities Comprehensive Care Plan Policy and Procedure dated 02/20/24, read in part, The comprehensive care plan .will be updated quarterly .or as needed/identifies as preference changes occur or healthcare need warrant. The BAPTIST VILLAGE COMMUNITIES BED RAIL POLICY AND PROCEDURE dated 02/20/24, read in part, Resident care plan will include use of bed rails as evaluated. 1. Resident #4 had diagnoses which included fracture of right lower leg and need for assistance with personal care. On 07/17/24 at 7:45 a.m., Resident #4 was observed in bed with two bed rails up on each side of the head of the bed. Resident #4's care plan did not document the use of bed rails. On 07/17/24 at 12:29 p.m., MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure oxygen tubing and concentrator filters were changed per physician's order for one (#4) of one resident sampled for respiratory care. The DON identified 11 residents used supplemental oxygen in the facility. Findings: The Baptist Village Communities Oxygen Administration Procedure policy, dated 05/24, read in part, Change nasal cannula .weekly. Resident #4 had diagnoses which included chronic respiratory failure and chronic obstructive pulmonary disease. A physician's order, dated 04/10/24, documented change nasal cannula, clean filters, and dry concentrator filters one time weekly. On 07/15/24 at 7:59 a.m., Resident #4's oxygen tubing on the concentrator was dated 06/24/24. The oxygen tubing on the portable tank was dated 06/03/24. The concentrator filters had dust build up. On 07/15/24 at 3:33 p.m., LPN #3 stated oxygen tubing and concentrator filters were to be changed once a week. On 07/15/24 at 3:36 p.m., LPN #3 made observation of Resident #4's oxygen tubing and filters on the concentrator, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-19 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure staffing information, which included the facility name, date, actual hours worked for RNs, LPNs, CMAs, and CNAs, and the resident census was posted in a prominent place readily accessible to residents and visitors. The DON identified 101 residents resided in the facility. Findings: On 07/15/24 at 7:14 a.m., a tour of the memory care unit was conducted to locate posted nursing staffing information. A plastic note holder located outside of the nurses' station had a daily assignment sheet, there was a list of staff members working the 7:00 a.m. to 3:00 p.m. shift. The date 07/15/24 was located near the left upper side of the page. There was no census or actual hours worked documented. There were no RNs listed on the page. On 07/17/24 at 7:05 a.m., a tour of the facility was conducted to locate posted nursing staffing information. Plastic note holders were located on each unit with daily assignment sheets, there was a list of staff members working the 7:00 a.m. to 3:00 p.m. shift. The date 07/15/24 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain infection control while handling wet linens. The DON identified 28 resident resided on the memory care unit. Findings: A Infection Control Policy, dated 02/02/24, read in part, The objective of this requirement is for health center to develop a comprehensive infection control policy that establishes a health center-wide system for the prevention, identification, investigation, and control of infections of residents. A Personal Protective Equipment Use to Prevent Spread of Multidrug-resistant Organisms policy, dated 02/20/24, read in part, Use of PPE is based on the team member interaction with residents and the potential for exposure to blood, bodily fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). On 07/15/24 at 9:35 a.m., a wet cloth bed pad, a wet blanket, a wet gown, and a clear trash bag…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-07-19 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a facility assessment was updated annually. The DON identified 101 residents resided in the facility. Findings: A Facility Assessment Tool, documented the date of assessment or update was 11/21/17. It documented the date the facility assessment was reviewed with QAA/QAPI was 12/13/17. On 07/19/24 at 9:23 a.m., the Administrator stated the facility assessment was to be updated annually. On 07/19/24 at 9:27 a.m., the Administrator stated their process was to change any information that required to be updated in the facility assessment. On 07/19/24 at 9:29 a.m., the Administrator reviewed the facility assessment. They stated according to you it has not been updated.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$28,695 in federal fines across 2 penalties.
- $10,358 — penalty dated 2025-10-01
- $18,337 — penalty dated 2024-07-19
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BAPTIST VILLAGE RETIREMENT COMMUNITIES OF OKLAHOMA, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 09/26/1993 |
| BANCFIRST | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 03/12/2025 |
| ABBOTT, PAUL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/18/2025 |
| BARRETT, JEAN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2024 |
| BELL, KEVIN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/17/2020 |
| BRIGGS, PARNIECE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/18/2025 |
| BURROWS, DOUG | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/18/2025 |
| DAVIS, FRANK | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/29/2022 |
| ENLOW, LINDA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/28/2023 |
| FISHER, TODD | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/30/2021 |
| FUCHS, KELLYE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/28/2023 |
| GANDY, MARK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 11/17/2021 |
| GIBBS, GEORGE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2024 |
| GIBBS, LINDA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/30/2021 |
| GODDARD, CATHERINE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/18/2025 |
| HAYNES, NAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 11/18/2025 |
| JOHNSON, MICHAEL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2024 |
| JOHNSON, WILL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/17/2020 |
| KOONS, BRIAN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/18/2025 |
| MATLOCK, MICHAEL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2019 |
| MCFARLAND, RANDALL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 11/19/2024 |
| MCPHERSON, ANDY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/18/2025 |
| MILES, JUDY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/28/2023 |
| MILLER, EDDIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2024 |
| MINK, JACQUELINE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/30/2021 |
| RUSSELL, KERRY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2024 |
| SCOTT, PAUL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/29/2022 |
| SMITH, MARGARET | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2024 |
| STAATS, SAMUEL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/19/2024 |
| TRENTHAM, MATTHEW | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 11/28/2023 |
| TURNER, JAMES | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 11/28/2023 |
| FLUKE, LAURI | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 06/01/2021 |
| PIERCE, WILLIAM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/1990 |
| ROOKER, SUSAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/19/2019 |
| RUSSELL, MARY | Individual | CORPORATE OFFICER | — | since 11/19/2019 |
| SHORT, WENDELL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2013 |
| STEWART, FRIEDA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/20/2019 |
| THOMAS, STEVEN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2012 |
| HALL, MARTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2013 |
CMS files one row per role, so the 87 rows in the source record cover these 39 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375381. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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