Inspection Reports for Baptist Village of Oklahoma City

9700 MASHBURN BOULEVARD, OKLAHOMA CITY, OK, 73162

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 0.6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

88% better than Oklahoma average
Oklahoma average: 4.9 deficiencies/year

Deficiencies per year

4 3 2 1 0
2020
2021
2022
2023
2025

Census

Latest occupancy rate 35 residents

Based on a February 2025 inspection.

Census over time

24 28 32 36 40 Jan 2020 Jul 2021 Feb 2025
Inspection Report Renewal Capacity: 170 Deficiencies: 0 Jul 8, 2025
Visit Reason
This document serves as a license renewal for the Baptist Village of Oklahoma City, certifying the facility to continue operating as a Continuum of Care Facility.
Findings
The license renewal certifies that the facility meets the provisions of the Oklahoma Statutes and rules and regulations adopted by the State Board of Health. No deficiencies or violations are noted in this document.
Report Facts
Maximum licensed beds: 170
Inspection Report Renewal Census: 35 Deficiencies: 0 Feb 4, 2025
Visit Reason
A relicensure survey was conducted from February 3, 2025 through February 4, 2025 to assess compliance for renewal of the facility's license.
Findings
No deficiencies were cited during the relicensure survey conducted at the Assisted Living Center.
Report Facts
Facility Census: 35
Inspection Report Renewal Deficiencies: 0 Oct 26, 2023
Visit Reason
The inspection was conducted as a relicensure survey from October 24 through October 25, 2023, to assess compliance for renewal of the facility's license.
Findings
No deficiencies were cited during the relicensure inspection.
Inspection Report Renewal Capacity: 170 Deficiencies: 0 Aug 12, 2022
Visit Reason
This document is a license renewal issued to Baptist Village Retirement Communities of Oklahoma, Inc. to conduct and maintain a Continuum of Care Facility.
Findings
The document certifies the facility's license renewal with a maximum capacity of 170 beds, effective from 07/17/2022 through 07/16/2025.
Report Facts
Maximum licensed beds: 170
Notice Capacity: 170 Deficiencies: 0 Aug 26, 2021
Visit Reason
This document serves as a license renewal issued to Baptist Village Retirement Communities of Oklahoma, Inc. to conduct and maintain a continuum of care facility.
Findings
The license certifies the facility's capacity to operate with a maximum of 120 nursing facility beds and 50 assisted living beds. No deficiencies or inspection findings are noted in this document.
Report Facts
Maximum nursing facility beds: 120 Maximum assisted living beds: 50
Inspection Report Complaint Investigation Census: 30 Deficiencies: 1 Jul 13, 2021
Visit Reason
A complaint investigation was conducted due to allegations that the facility failed to ensure residents' visitation rights were not restricted and that residents had unrestricted rights to leave the center.
Findings
The investigation found that the facility failed to accommodate residents' visitation preferences for four sampled residents, restricting visitation based on vaccination status and not adequately informing residents or families of visitation policy changes.
Complaint Details
Complaint #OK00057300 was substantiated. The allegation was that the facility failed to ensure residents' visitation was not restricted and that residents had unrestricted rights to leave the center. Deficient practice was substantiated related to this allegation.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failed to ensure residents' rights for accommodation of preferences regarding visitation for four sampled residents.SS=F
Report Facts
Census: 30 Number of residents sampled: 4 Investigation dates: 2021-07-12 to 2021-07-13 Plan of Correction completion date: Aug 2, 2021 Revisit date: Dec 13, 2022
Employees Mentioned
NameTitleContext
Barbara HannaAdministratorNamed as facility administrator in multiple documents
Katie StagnerEnforcement Reviewer/AnalystSigned enforcement letter
Tempal KillmanAdministrative AssistantSigned acceptance letter of plan of correction
Lisa CalvinEnforcement AnalystSigned revisit letter confirming correction
Inspection Report Renewal Capacity: 170 Deficiencies: 0 Jul 17, 2020
Visit Reason
The document is a renewal license issued to Baptist Village Retirement Communities of Oklahoma, Inc. for the Baptist Village of Oklahoma City facility, confirming the renewal license application filed on July 15, 2020, meets regulatory requirements.
Findings
The Oklahoma State Department of Health approved the renewal license application and related documents, authorizing the facility to continue operating as a Continuum of Care Facility with a maximum capacity of 170 beds.
Report Facts
Maximum licensed beds: 170
Employees Mentioned
NameTitleContext
Espaniola BowenAdministrative Program ManagerSigned the renewal license approval letter
Michael ToddHealth Planning SpecialistContact person for licensing questions mentioned in the letter
Lance FryeCommissioner of HealthSigned the renewal license certificate
Inspection Report Re-Inspection Census: 35 Deficiencies: 2 Jan 29, 2020
Visit Reason
A State Licensure survey was conducted at the facility on January 29, 2020, as a re-licensure survey to assess compliance with regulatory requirements.
Findings
Deficient practices were identified related to validation of certified medication aide skills and staff qualifications including first aid and CPR training. The deficiencies had the potential for more than minimal harm. A follow-up offsite/paper revisit was conducted on November 9, 2020, confirming all deficiencies were corrected effective March 13, 2020.
Deficiencies (2)
Description
Failed to ensure validation of certified medication aide skills prior to medication administration.
Failed to ensure direct care staff were trained in first aid and cardiopulmonary resuscitation (CPR).
Report Facts
Census: 35 Survey dates: 3 Surveyor hours on-site: 32.5
Employees Mentioned
NameTitleContext
James DuehningAdministratorFacility administrator named in the report
Lisa CalvinEnforcement Reviewer/AnalystSigned the offsite revisit letter confirming correction of deficiencies
Sue DavisEnforcement CoordinatorSigned the initial enforcement letter

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