Inspection Reports for
Baptist Village of Enid
5801 NORTH OAKWOOD ROAD, ENID, OK, 73703
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Oklahoma average
Oklahoma average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
163% occupied
Based on a July 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 5, 2024
Visit Reason
The inspection was conducted based on complaints regarding medication administration errors, medication labeling issues, and infection prevention program deficiencies.
Complaint Details
The complaint investigation found substantiated issues with medication administration errors, medication labeling, and infection prevention program deficiencies.
Findings
The facility failed to ensure medications were administered as ordered for one resident, failed to label medications properly on medication carts, and failed to maintain a water management program to prevent Legionella and other waterborne pathogens.
Deficiencies (3)
F 0755: The facility failed to ensure medications were administered as ordered for one resident, including administering blood pressure medications despite parameters to hold them based on blood pressure readings.
F 0761: The facility failed to ensure a medication was labeled for one of two medication carts observed, with a medication box lacking a proper label including resident name and medication details.
F 0880: The facility failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system.
Report Facts
Residents receiving blood pressure medications: 53
Residents in facility: 63
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 4
Date: Jul 17, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to notify physicians and family members of changes in resident conditions, failure to allow anonymous grievance filing, failure to timely report misappropriation of property, and failure to assess and monitor residents for changes in condition.
Complaint Details
The visit was complaint-related involving failure to notify physicians and family members of changes in condition, grievance process deficiencies, failure to report misappropriation of property, and failure to monitor a resident's condition. Substantiation status is not explicitly stated.
Findings
The facility failed to notify the physician and resident representative of changes in condition for sampled residents, did not ensure anonymous grievance filing or proper grievance signage, failed to report an allegation of misappropriation of property to the state, and failed to assess and monitor a resident for worsening symptoms.
Deficiencies (4)
F 0580: The facility failed to notify the physician for one resident and the resident representative for another regarding changes in condition.
F 0585: The facility failed to ensure residents and representatives could file grievances anonymously and did not post information identifying the grievance official.
F 0609: The facility failed to timely report an allegation of misappropriation of property to the Oklahoma State Department of Health and did not document the investigation.
F 0675: The facility failed to assess and monitor one resident for worsening symptoms after a change in condition was noted.
Report Facts
Residents identified in facility: 65
Residents affected: 3
Residents affected: 7
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
A complaint investigation was conducted due to allegations that the facility failed to prevent physical, verbal, or psychosocial abuse, failed to assess and intervene for changes in condition, and failed to report abuse to the State Agency.
Complaint Details
The complaint alleged failure to ensure residents were not abused and failure to report abuse to the State Agency. The investigation was unannounced and included a sample of four residents. No deficiencies were found and the complaint was not substantiated.
Findings
The investigation included observations, interviews, and record reviews. No deficiencies were cited as a result of the complaint investigation.
Report Facts
Facility Census: 28
Complaint Investigation Dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tempal Killman | Enforcement Analyst | Signed the cover letter and report |
Inspection Report
Original Licensing
Capacity: 130
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
This document is an initial licensing certificate issued to Baptist Village Retirement Communities of Oklahoma, Inc. to conduct and maintain a Continuum of Care Facility.
Findings
The document certifies that the facility is licensed with a maximum capacity of 130 beds, effective from December 1, 2023, through May 29, 2024.
Report Facts
Maximum licensed beds: 130
Inspection Report
Routine
Census: 64
Deficiencies: 3
Date: Oct 20, 2023
Visit Reason
The inspection was conducted to assess compliance with wound care, infection prevention and control, and pest management programs at the nursing home.
Findings
The facility failed to ensure wound care was completed as ordered for one resident, maintain proper infection control during perineal and catheter care for another resident, and implement an effective pest management program to prevent rodents.
Deficiencies (3)
F 0684: The facility failed to ensure wound care was completed as ordered for one of two sampled residents reviewed for wound care. Documentation showed incomplete wound care on specified dates and lack of updated orders for dressing changes.
F 0880: The facility failed to ensure staff maintained infection control during perineal and catheter care for one of 19 sampled residents. Staff were observed not changing gloves between tasks, increasing infection risk.
F 0925: The facility failed to ensure an effective pest management program was in place to prevent rodents. Observations and records documented mouse and rat droppings in resident areas and staff desks, with management acknowledging ongoing rodent problems.
Report Facts
Resident census: 24
Resident census: 64
Inspection Report
Routine
Census: 64
Deficiencies: 7
Date: Oct 20, 2023
Visit Reason
Routine inspection of Baptist Village of Enid nursing home to assess compliance with regulatory requirements including resident rights, facility maintenance, medication management, wound care, infection control, and pest control.
Findings
The facility had multiple deficiencies including failure to provide required Medicaid/Medicare notices to residents, poor maintenance of the facility environment, incomplete care plans for medications, inadequate wound care documentation, failure to monitor side effects of medications, improper infection control practices during perineal and catheter care, and ineffective pest control resulting in rodent presence.
Deficiencies (7)
F 0582: The facility failed to provide ABN and NOMNC letters to two of three sampled residents discharged with benefit days remaining.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, with multiple areas of carpet and flooring in disrepair and mold present.
F 0657: The facility failed to update the care plan for one resident to address the use of Wellbutrin and Librium medications.
F 0684: The facility failed to ensure wound care was completed as ordered for one resident with a chronic foot ulcer.
F 0757: The facility failed to monitor for side effects related to the use of multiple medications for one resident.
F 0880: The facility failed to maintain infection control during perineal and catheter care for one resident, with staff not changing gloves appropriately.
F 0925: The facility failed to ensure an effective pest management program to prevent rodents, with rodent droppings found in resident drawers and staff areas.
Report Facts
Resident census: 64
Resident census: 24
Medication doses administered: 37
Medication doses administered: 74
Medication doses administered: 18
Medication doses administered: 25
Medication doses refused: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided census information and statements about facility conditions | |
| MDS Coordinator #2 | Reported missing ABN and NOMNC letters for residents | |
| ADON | Interviewed regarding care plan updates, medication monitoring, and infection control practices | |
| Maintenance Supervisor | Acknowledged facility maintenance issues and rodent problems | |
| CNA #1 and CNA #2 | Observed providing perineal and catheter care with infection control deficiencies | |
| RN #1 | Observed rodent droppings in resident room drawers |
Inspection Report
Routine
Census: 64
Deficiencies: 5
Date: Apr 22, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, care planning, respiratory care, pharmacy review, and infection prevention at Baptist Village of Enid.
Findings
The facility was found deficient in notifying physicians of frequent medication refusals, updating and revising person-centered care plans, assessing oxygen therapy needs, acting on pharmacy medication review recommendations, and maintaining infection prevention documentation and proper oxygen equipment handling.
Deficiencies (5)
F 0580: The facility failed to ensure a physician was notified of frequent medication refusals for one resident (#50).
F 0657: The facility failed to review and revise the person-centered care plan for one resident (#9) to reflect oxygen use.
F 0695: The facility failed to assess a resident's (#9) need for oxygen according to professional standards, lacking orders for oxygen saturation monitoring frequency and administration parameters.
F 0756: The facility failed to ensure the physician acted upon pharmacy recommendations for medication regimen review for two residents (#50 and #62).
F 0880: The facility failed to document tracking and trending of antibiotic use for 11 of 12 months and failed to ensure proper handling and changing of disposable oxygen equipment for one resident (#9).
Report Facts
Residents present: 64
Residents with oxygen orders: 11
Residents reviewed for care plans: 13
Residents sampled for medication review: 5
Residents with medication refusal issue: 1
Residents with oxygen therapy issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Identified resident census and provided information on medication regimen reviews and infection control tracking | |
| Assistant Director of Nursing (ADON) | Asked about infection tracking and trending responsibilities | |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication refusal procedures and physician notification |
| LPN #3 | Licensed Practical Nurse | Interviewed about oxygen administration orders and monitoring |
| LPN #4 | Licensed Practical Nurse | Interviewed about oxygen equipment maintenance and usage |
| CMA #1 | Certified Medication Aide | Interviewed about medication refusal procedures |
| CNA #1 | Certified Nursing Assistant | Observed handling oxygen equipment improperly |
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