Cycle 1
Health 2024-12-05 · Fire 2024-12-05
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Enid, OK
Baptist Village Of Enid
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5801 North Oakwood Road, Enid, OK
(580) 249-2600
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
65
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-03-04
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
0.33
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
3.23
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
4.75
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
4.38
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
0.03
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
5.64
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,264
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9901
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.46
Baseline 20.69% · Performance 20.29% · Measure score 2.46 · Achievement 2.46 · Improvement 0.58
Healthcare-associated infections
8.42
Baseline 6.29% · Performance 5.32% · Measure score 8.42 · Achievement 8.42 · Improvement 7.02
Total nurse turnover
0
Baseline 60.82% · Performance 83.10% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.83
Baseline 5.08 hours · Performance 4.17 hours · Measure score 3.83 · Achievement 3.83 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 157 · Observed rate 10.19% · Lower 95% interval 7.47% |
| Discharge to community | 50.41% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 47.37% · Lower 95% interval 43.41% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 61.11% |
95.27%
34.2 pts worse
|
Numerator 55 · Denominator 90 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 90 |
| Discharge self-care score | 71.83% |
53.69%
18.1 pts better
|
Numerator 51 · Denominator 71 |
| Discharge mobility score | 70.42% |
50.94%
19.5 pts better
|
Numerator 50 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 90 · Adjusted rate 3.11% |
| Healthcare-associated infections requiring hospitalization | 5.32% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 2% · Lower 95% interval 2.77% |
| Staff COVID-19 vaccination coverage | 1.3% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 77 |
| Staff flu vaccination coverage | 14.42% |
42%
27.6 pts worse
|
Numerator 15 · Denominator 104 |
| Discharge function score | 69.01% |
56.45%
12.6 pts better
|
Numerator 49 · Denominator 71 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 7.41% |
25.2%
17.8 pts worse
|
Numerator 4 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.3
0.1 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.4 |
2.9
1.5 pts worse
|
1.8
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 4.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.0% |
90.3%
22.3 pts worse
|
93.4%
25.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.8% · Q2 60.4% · Q3 70.5% · Q4 81.6% · 4Q avg 68.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
94.6%
3.6 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
4.5%
0.4 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.7% · Q3 2.3% · Q4 4.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
3.3%
3.9 pts worse
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.4% · Q3 10.0% · Q4 6.2% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.6%
0.8 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 3.0% · Q4 2.9% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
25.3%
5.8 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 21.4% · Q3 17.1% · Q4 16.7% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
18.6%
1 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.2% · Q3 17.2% · Q4 16.7% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.0% |
15.5%
1.5 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
14.1%
4.8 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.8% · Q3 8.8% · Q4 8.3% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
2.1%
1.5 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.2% · Q3 4.8% · Q4 5.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.8%
0.4 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 2.4% · Q4 6.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.1% |
17.8%
7.7 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 11.8% · Q3 9.7% · Q4 2.2% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.1%
2.9 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 12.3% · Q3 4.6% · Q4 0.0% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.9% |
75.0%
43.1 pts worse
|
81.7%
49.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 50.0% · Q3 34.2% · Q4 12.0% · 4Q avg 31.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.3% |
17.1%
7.2 pts worse
|
12.0%
12.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 22.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.9%
0.8 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.3% |
74.0%
8.7 pts worse
|
79.7%
14.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
27.0%
4.3 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 17.9% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-20 · Fire 2023-10-20
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-04-22 · Fire 2022-04-22
5 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-13
F · Potential for more than minimal harm
2023-10-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-10-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-02
E · Potential for more than minimal harm
2022-04-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-05-25
E · Potential for more than minimal harm
2022-04-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-05-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-07-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-17
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-17
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2024-08-16
E · Potential for more than minimal harm
2023-10-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-10-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-10-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-10-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-10-20
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-10-20
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 2023-12-15
D · Potential for more than minimal harm
2023-10-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
E · Potential for more than minimal harm
2022-04-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-05-25
E · Potential for more than minimal harm
2022-04-22
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 2022-05-25
E · Potential for more than minimal harm
2022-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-25
E · Potential for more than minimal harm
2022-04-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-05-25
E · Potential for more than minimal harm
2022-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-25
Penalties and ownership
What sits behind the stars
Ownership
Baptist Village Retirement Communities Of Oklahoma, Inc
5% Or Greater Direct Ownership Interest · Organization
Abbott, Paul
Corporate Director · Individual
Bancfirst
5% Or Greater Mortgage Interest · Organization
Baptist Village Retirement Communities Of Oklahoma, Inc
Operational/Managerial Control · Organization
Barrett, Jean
Corporate Director · Individual
Bell, Kevin
Corporate Director · Individual
Briggs, Parniece
Corporate Director · Individual
Burrows, Doug
Corporate Director · Individual
Coleman, Ricky
Operational/Managerial Control · Individual
Davis, Frank
Corporate Director · Individual
Enlow, Linda
Corporate Officer · Individual
Fisher, Todd
Corporate Officer · Individual
Fluke, Lauri
Operational/Managerial Control · Individual
Fluke, Lauri
Corporate Officer · Individual
Fuchs, Kellye
Corporate Director · Individual
Gandy, Mark
Corporate Director · Individual
Gandy, Mark
Corporate Officer · Individual
Gibbs, George
Corporate Director · Individual
Gibbs, Linda
Corporate Director · Individual
Goddard, Catherine
Corporate Director · Individual
Haynes, Nan
Corporate Director · Individual
Johnson, Michael
Corporate Director · Individual
Johnson, Will
Corporate Officer · Individual
Koons, Brian
Corporate Director · Individual
Matlock, Michael
Corporate Director · Individual
Mcfarland, Randall
Corporate Director · Individual
Mcfarland, Randall
Corporate Officer · Individual
Mcpherson, Andy
Corporate Director · Individual
Miles, Judy
Corporate Director · Individual
Miller, Eddie
Corporate Director · Individual
Mink, Jacqueline
Corporate Director · Individual
Pierce, William
Operational/Managerial Control · Individual
Pierce, William
Corporate Officer · Individual
Rooker, Susan
Operational/Managerial Control · Individual
Rooker, Susan
Corporate Officer · Individual
Russell, Kerry
Corporate Director · Individual
Russell, Mary
Corporate Officer · Individual
Scott, Paul
Corporate Director · Individual
Short, Wendell
Operational/Managerial Control · Individual
Short, Wendell
Corporate Officer · Individual
Smith, Margaret
Corporate Director · Individual
Staats, Samuel
Corporate Director · Individual
Stewart, Frieda
Operational/Managerial Control · Individual
Stewart, Frieda
Corporate Officer · Individual
Thomas, Steven
Operational/Managerial Control · Individual
Thomas, Steven
Corporate Officer · Individual
Trentham, Matthew
Corporate Director · Individual
Trentham, Matthew
Corporate Officer · Individual
Turner, James
Corporate Director · Individual
Nearby options
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#2
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4-star overall rating with 4-star inspections with $3,174 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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