Cycle 1
Health 2025-10-01 · Fire 2025-10-01
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Oklahoma City, OK
Baptist Village of Oklahoma City
2-star overall rating with 2-star inspections with abuse icon flag with $34,272 in total fines with 2 recent health deficiencies
9700 Mashburn Blvd, Oklahoma City, OK
(405) 721-2466
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-06-01
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
0.58
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.48
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
4.28
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
6.34
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
5.54
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
7.57
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,118
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.28% · Performance 21.31% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.37% · Performance 9.35% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.28
Baseline 55.29% · Performance 54.37% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.27 hours · Performance 6.57 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.55% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 607 · Observed rate 11.2% · Lower 95% interval 9.97% |
| Discharge to community | 62.23% |
50.57%
11.7 pts better
|
Better than the National Rate · Eligible stays 578 · Observed rate 59.86% · Lower 95% interval 58.44% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.48% |
95.27%
4.2 pts better
|
Numerator 380 · Denominator 382 |
| Falls with major injury | 0.26% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 382 |
| Discharge self-care score | 69.37% |
53.69%
15.7 pts better
|
Numerator 188 · Denominator 271 |
| Discharge mobility score | 56.46% |
50.94%
5.5 pts better
|
Numerator 153 · Denominator 271 |
| Pressure ulcers or injuries, new or worsened | 2.62% |
2.29%
0.3 pts worse
|
Numerator 10 · Denominator 382 · Adjusted rate 2.93% |
| Healthcare-associated infections requiring hospitalization | 9.35% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 388 · Observed rate 8.51% · Lower 95% interval 6.74% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 187 |
| Staff flu vaccination coverage | 13.61% |
42%
28.4 pts worse
|
Numerator 26 · Denominator 191 |
| Discharge function score | 72.32% |
56.45%
15.9 pts better
|
Numerator 196 · Denominator 271 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 293 · Denominator 293 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 64 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 15.85% |
25.2%
9.3 pts worse
|
Numerator 26 · Denominator 164 |
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 1.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.9
1.4 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.3%
9.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
4.5%
3.3 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.7% · Q3 1.7% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
3.3%
1.6 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.9% · Q3 5.5% · Q4 8.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
3.6%
4.5 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 10.9% · Q3 8.3% · Q4 9.4% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
25.3%
7.1 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 16.7% · Q3 20.8% · Q4 20.8% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
18.6%
10.9 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 2.6% · Q3 7.0% · Q4 2.4% · 4Q avg 7.7% · 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 | 29.9% |
15.5%
14.4 pts worse
|
16.3%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 19.0% · 4Q avg 29.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.6% |
14.1%
17.5 pts worse
|
14.9%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.0% · Q2 24.4% · Q3 16.7% · Q4 34.6% · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.1%
1.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
2.8%
2.1 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.9% · Q3 5.0% · Q4 4.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
17.8%
11.3 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 31.0% · Q3 28.7% · Q4 28.5% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
5.1%
4.1 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
75.0%
23.9 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.6% · Q3 98.5% · Q4 99.7% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
17.1%
3.2 pts better
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 13.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.9%
1.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.9% · Q4 0.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
74.0%
23.2 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
27.0%
0.9 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 23.3% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2024-07-19
23 health deficiencies
Top issue: Resident Rights (7 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-06-15 · Fire 2023-06-15
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-07-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-03
E · Potential for more than minimal harm
2023-06-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-06-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-06-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-19
Inspection history
Recent health citations
G · Actual harm
2025-10-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-10-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-10
E · Potential for more than minimal harm
2024-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-09-25
K · Immediate jeopardy
2024-07-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-29
G · Actual harm
2024-07-19
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2024-08-29
G · Actual harm
2024-07-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-19
F803 · Nutrition and Dietary Deficiencies
Health
Ensure 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.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
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 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-29
C · Minimal harm
2024-07-19
F838 · Administration Deficiencies
Health
Conduct 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.
Corrected 2024-08-29
Penalties and ownership
What sits behind the stars
$15,935
2025-10-01
Fine
Fine · fine $15,935
Fine
$18,337
2024-07-19
Fine
Fine · fine $18,337
Fine
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
Davis, Frank
Corporate Director · Individual
Enlow, Linda
Corporate Director · Individual
Fisher, Todd
Corporate Director · 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
Hall, Martin
Operational/Managerial Control · Individual
Haynes, Nan
Corporate Director · Individual
Johnson, Michael
Corporate Director · Individual
Johnson, Will
Corporate Director · 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
Other facilities in reach
#1
The Health Center At Concordia
Oklahoma City, OK
5-star overall rating with 4-star inspections with $25,407 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
St. Ann's Skilled Nursing And Therapy
Oklahoma City, OK
4-star overall rating with 4-star inspections with 8 recent health deficiencies
#3
The Lakes
Oklahoma City, OK
1-star overall rating with 2-star inspections with $19,073 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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