Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baptist Village Of Oklahoma City during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral challenges was physically abused by a CNA during care, resulting in visible injuries and fear. The abuse was witnessed by another CNA, who delayed reporting the incident. Documentation and staff interviews confirmed the resident was not protected from abuse, as required by facility policy.
A resident who was unable to bear weight and required total assistance was transferred by three CNAs using an unsafe method, with a loose gait belt and lifting under the arms, resulting in pain and distress. Staff had reported the resident's decline and the need for a mechanical lift, but the care plan and transfer procedures were not updated, and interdisciplinary team meetings did not address the change in transfer needs.
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, leading to a deficiency in infection prevention and control. Staff were unaware of the need for these precautions, and residents reported incomplete use of PPE during care.
A CNA in a memory care unit was found to have physically restrained a resident with Alzheimer's and cognitive impairments by grabbing them to force them into a seated position. The resident, who was independent in ambulation, showed no physical harm upon assessment. The CNA was terminated following an investigation that confirmed the abuse allegation.
An Immediate Jeopardy situation was identified in a memory care unit due to unsafe conditions in the shower room. The door failed to close and lock automatically, allowing residents unsupervised access. The room had a wet floor, a plugged-in hair dryer, numerous bottles of personal care products, and an unlocked cabinet with razors. Emergency call lights were looped around grab bars, making them unusable. An LPN confirmed these conditions were against protocol, and 28 residents were potentially affected.
A resident with parkinsonism and pain experienced a fall resulting in a fractured finger. Despite orders for buddy taping and a recommendation for a splint, the facility failed to document the application of the buddy tape and did not provide range of motion exercises or physical therapy. The resident reported not receiving therapy or seeing an orthopedic surgeon for two months, leading to a decline in hand functionality.
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by their policy. Four residents were not reviewed for GDR, despite being on multiple psychotropic medications. For instance, a resident with dementia and depression was on escitalopram and trazodone without any documented recommendation for a GDR. Another resident with emotional lability and anxiety was prescribed multiple medications, and although the pharmacist suggested a GDR, no changes were made. Additionally, a resident with Alzheimer's disease and dementia was on several medications, and despite experiencing a fall, there was no documentation of a GDR review.
The facility did not post the breakfast menu as required by their policy, which states that menus should be posted at least one week in advance and in a readable font size. This was observed on two occasions, and the Registered Dietician was unsure if the menu was posted. The facility houses 101 residents.
The facility did not inform residents of their right to hold resident council meetings without staff presence, as required by their policy. During interviews, nine residents expressed unawareness of this right, and a social service staff member admitted to not knowing the policy, indicating a need for review.
The facility did not ensure the ombudsman's contact information was accessible to residents, interfering with their rights to communicate with the state's ombudsman office. Residents were unaware of the ombudsman's role or contact details. The information was posted in small print and out of view for wheelchair users, with no information board on the skilled halls.
The facility failed to distribute mail to residents on weekends. Nine members of the resident council reported that mail was not distributed on weekends, and social services staff confirmed that mail delivered on Saturdays was not passed out until Monday. This affected the 101 residents residing in the facility.
The facility did not ensure survey results were easily accessible to residents and visitors. Resident council members were unaware of the location of the state inspection book, and while a sign on the LTC halls indicated survey results were at the front desk, there was no such information in the skilled halls.
The facility did not ensure residents and their representatives could file grievances anonymously or were informed about the grievance official. Despite a policy stating the provision of a grievance mechanism without fear of retaliation, residents were unaware of how to file grievances, and social services staff were unsure of the grievance official's identity.
A resident with parkinsonism and pain experienced a fall resulting in a fractured finger. Despite a physician's order for ice packs and an orthopedic referral, the resident did not receive timely care. The resident was not seen by a provider for nearly a month, and the orthopedic consultation was delayed for over two months. An LPN acknowledged the failure to set up the appointment, and the DON confirmed the delay, noting that only ice packs and Tylenol were provided during the interim.
The facility failed to assess and document the use of bed rails for two residents, one with a leg fracture and another with hemiplegia. Both residents used bed rails without documented assessments, physician's orders, or informed consent, as confirmed by facility staff.
The facility failed to comply with its policies on food storage, handling, and sanitization, resulting in several deficiencies. Food items were not labeled or stored properly, and hot food temperatures were not maintained or documented as required. Additionally, staff did not change gloves between tasks, and the dishwasher lacked sanitizer solution, compromising cleanliness. These lapses indicate a failure to adhere to established food safety protocols.
The facility failed to ensure call devices were accessible for two residents in the memory care unit. One resident with dementia and heart failure had a call light cord hanging over the head of the bed, while another with diastolic heart failure and Alzheimer's had cords over the foot of an empty bed. A CNA confirmed the inaccessibility, and the DON stated call devices should always be within reach.
A facility failed to promote resident dignity by not following its policy for meal assistance. A resident with Alzheimer's disease, requiring supervision with eating, was assisted by an LPN who stood while helping the resident, contrary to the policy that staff should be seated. Both the LPN and the DON acknowledged the policy violation.
A facility failed to ensure a resident had a physician order and assessment for self-administering a nasal spray. The resident was observed with the spray on their nightstand and confirmed self-administration. An LPN and the DON acknowledged the absence of required documentation for self-administration.
A facility failed to accurately complete a quarterly MDS assessment for a resident with parkinsonism and a psychotic disorder. Despite a physician's order for Nuplazid, an antipsychotic, and its documented administration, the admission assessment incorrectly noted that the resident had not received antipsychotic medications. This error was confirmed by the MDS Coordinator.
The facility failed to update care plans for two residents to include the use of bed rails, as required by their policies. A resident with a leg fracture and another with hemiplegia had bed rails in use, but their care plans did not document this. The MDS Coordinator confirmed the omission, and the DON acknowledged the presence of bed rails since admission.
A facility failed to follow physician's orders for a resident with chronic respiratory failure and COPD by not changing oxygen tubing and cleaning concentrator filters weekly. Observations revealed outdated tubing and dusty filters, which an LPN confirmed were not maintained as required.
The facility did not post complete nurse staffing information, including actual hours worked and resident census, in a prominent place. Observations on multiple dates revealed that assignment sheets lacked this information, and no RNs were listed. The AIT confirmed the omission of hours and census details.
A facility failed to maintain infection control when a CNA handled wet linens without wearing gloves and carried them down the hall without placing them in a bag, allowing them to touch their clothing. The DON confirmed that wet linens should be bagged and gloves worn when handling soiled linens, as per the facility's infection control policy.
The facility did not update its facility-wide assessment annually as required. The last update was in 2017, and the Administrator confirmed that the assessment had not been revised since then, despite having 101 residents. The process for updating information was acknowledged but not executed.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident with severe cognitive impairment, multiple chronic conditions, and a history of behavioral challenges was physically abused by a certified nurse aide (CNA) during care. The resident, who required substantial assistance with transfers and had a BIMS score indicating severe cognitive impairment, was observed to have two red marks on their right leg that were tender to touch. The abuse occurred when the resident became aggressive and resistant to care, leading the CNA to respond by grabbing the resident's face, twisting their head and fingers, pulling their hair, and punching the resident twice in the leg. The incident was witnessed by another CNA, who later reported the abuse to a nurse. The resident was able to recall being hit and having their hair pulled during an assessment, although they could not identify the perpetrator by name but indicated it was a male. Documentation from staff statements and progress notes confirmed the physical abuse, with the nurse and DON both assessing the resident for injuries and noting the presence of red marks and tenderness on the leg. The resident's family was notified of the incident and confirmed that the resident reported being struck by a male staff member. Staff interviews indicated that the resident had not previously complained about staff and that this was the only reported incident of abuse involving the CNA in question. The incident caused the resident to express fear of the CNA involved, and staff also reported feeling afraid of the CNA due to their actions. The facility's abuse policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The events leading to the deficiency included the CNA's reaction to the resident's aggressive behavior by inflicting physical harm, the delay in reporting the abuse by the witnessing CNA, and the subsequent identification of physical injuries consistent with the reported abuse. The facility's documentation and staff interviews confirmed that the resident was not protected from abuse as required by policy.
Unsafe Transfer Practices Result in Resident Distress
Penalty
Summary
The facility failed to provide safe transfer procedures for a resident who was unable to bear weight on their lower extremities and required total assistance. During an observed transfer from bed to wheelchair, three CNAs assisted the resident using a loose-fitting gait belt placed around the upper body, while two CNAs lifted the resident under the arms, causing the resident to moan and grimace in pain. The resident's care plan indicated a two-person assist for transfers, but the method used placed undue stress on the resident's arms and shoulders, and the resident was unable to communicate their pain level. Staff interviews revealed that CNAs had reported the resident's decline and the need for a mechanical lift to the charge nurse and hospice staff over the preceding months, expressing concerns for both resident and staff safety. Despite these reports, the care plan and transfer method were not updated to reflect the resident's increased needs. The interdisciplinary team meetings did not document discussion of transfer needs, and there was a lack of timely reassessment and adjustment of the transfer process, even as staff recognized the resident was no longer able to assist in transfers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, leading to a deficiency in infection prevention and control. Resident #1, who had diabetes mellitus with peripheral angiopathy and gangrene, was dependent on staff for daily living activities and had a central line for antibiotic administration. Resident #3, diagnosed with cystitis and bacteremia, also relied on staff for daily activities and had an indwelling catheter. Observations revealed that their rooms lacked signage indicating the need for enhanced barrier precautions, and there were no PPE carts nearby. Interviews with staff highlighted a lack of understanding and implementation of enhanced barrier precautions. LPN #1 and LPN #2 were unaware of what enhanced barrier precautions entailed, although they were familiar with standard and isolation precautions. The Director of Nursing (DON) indicated that such precautions were only implemented with a confirmed communicable disease diagnosis. Residents reported that while staff washed hands and wore gloves during care, they did not wear gowns, which are part of enhanced barrier precautions. This oversight was only addressed after it was brought to the facility's attention.
CNA Physically Restrains Resident in Memory Care
Penalty
Summary
The facility failed to prevent a certified nursing assistant (CNA) from physically restraining a resident, which constitutes a deficiency in ensuring residents are free from physical restraints unless needed for medical treatment. The incident involved a resident with Alzheimer's, anxiety, depression, and cognitive communication deficit, who was severely cognitively impaired and had a history of wandering. The deficiency was identified when an incident report documented that, following an allegation of abuse, camera footage showed the CNA grabbing the resident by the arm and shirt to force them into a seated position. The resident, who resided in memory care and was independent with ambulation, did not exhibit any physical harm such as redness, bruising, or swelling upon assessment after the incident. The CNA involved was terminated following the investigation that substantiated the abuse allegation. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property defines abuse as the willful infliction of injury or unreasonable confinement, which was violated in this case.
Immediate Jeopardy Due to Unsafe Shower Room Conditions
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified in a memory care unit due to the facility's failure to ensure the shower room door closed and locked automatically, preventing residents from entering unsupervised. During an initial tour, the shower room was found with a wet and slippery floor, a plugged-in hair dryer placed in the grab bar area, and more than ten bottles of shampoos, conditioners, alcohol-based surface cleaner, and shaving cream covering over half of the shower bench. Additionally, the cabinet in the shower room was unlocked, with razors within reach, and two emergency call lights were looped around grab bars, rendering them unusable for alerting staff for assistance. The Director of Nursing (DON) identified that 28 residents resided on the memory care unit, all potentially affected by these hazards. An LPN confirmed that the shower room door was supposed to be shut and locked, the hair dryer should not have been plugged in, and chemicals should not have been present. The running water was acknowledged as a hazard, and the call lights should not have been wrapped around the grab bar. It was also stated that residents were not to be in the shower room without staff supervision.
Removal Plan
- The shower room door was trimmed to ensure self-closure.
- The hair dryer had been removed from the grab bar and locked in the shower room cabinet. The hair dryers were removed from the locked cabinet and completely removed from the shower room.
- The ten bottles of shampoos, conditioners, alcohol-based surface cleaner and shaving cream were removed from the shower room.
- The cabinet in the shower room was locked.
- All nursing team members in the building were educated, and all remaining team members were educated. Proof of education is attached.
Failure to Prevent Decrease in Range of Motion for Resident's Fractured Finger
Penalty
Summary
The facility failed to prevent a decrease in range of motion for a resident with a fractured finger. The resident, who had diagnoses including parkinsonism and pain, experienced a fall resulting in a fracture of the right ring finger. Despite a physician's order to buddy tape the fingers and a subsequent recommendation for a finger splint and surgical evaluation, there was no documentation that the buddy tape was applied as ordered. The resident reported not receiving therapy for the finger and not seeing an orthopedic surgeon for two months following the injury. Observations confirmed the resident's inability to straighten the ring finger, and the facility did not provide range of motion exercises or physical therapy to address the fracture. The LPN and DON acknowledged the lack of implementation of the buddy tape order and the absence of range of motion or physical therapy interventions. This inaction contributed to the resident's decline in hand functionality, as noted by the LPN, who was unaware of the resident's ability to straighten the finger prior to the fracture.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by their policy. The report highlights that four residents were not reviewed for GDR, despite being on multiple psychotropic medications. For instance, Resident #40, diagnosed with dementia and depression, was on escitalopram and trazodone without any documented recommendation for a GDR. The pharmacist stated they were following the resident's wishes, indicating a lack of adherence to the facility's policy. Resident #14, with emotional lability and anxiety, was prescribed multiple medications, including Effexor, Xanax, Seroquel, and lamotrigine. Although the pharmacist suggested a GDR, the resident did not want their medications changed, and the APRN confirmed that no GDR recommendation was made. Similarly, Resident #33, with Alzheimer's disease and dementia, was on several medications, including melatonin, bupropion, Zoloft, risperidone, and Seroquel. Despite experiencing a fall resulting in a fracture, there was no documentation of a GDR review, and subsequent medication reviews did not address the need for GDR. Resident #41, admitted with dementia and behavioral disturbances, was prescribed quetiapine, despite FDA warnings against its use in dementia-related psychosis. The pharmacist deemed it appropriate, but the report notes the increased risk of death associated with such treatment. Overall, the facility's failure to adhere to its policy on GDR and non-pharmacological interventions for psychotropic medications resulted in deficiencies in medication management for these residents.
Failure to Post Breakfast Menu
Penalty
Summary
The facility failed to ensure that the breakfast menu was posted, as required by their policy. The policy, dated January 24, mandates that menus be posted at least one week in advance and in a font size that is easily readable by all residents. On July 12, at 8:31 a.m., it was observed that no breakfast menu was posted. Additionally, on July 16, at 2:08 p.m., the Registered Dietician reported uncertainty about whether the menu was posted. This deficiency affected the facility, which houses 101 residents, as reported by the Director of Nursing (DON).
Failure to Inform Residents of Right to Private Meetings
Penalty
Summary
The facility failed to notify residents of their right to hold resident council meetings without staff presence, which interfered with their ability to organize and participate in such meetings privately. The deficiency was identified through record review and interviews, revealing that the residents were unaware of this right. The facility's policy on Resident Rights: Resident and Family Groups, dated 02/20/24, stated that team members, visitors, and other guests may only attend the meeting upon invitation. However, during an interview on 07/17/24, nine residents in attendance expressed their lack of awareness regarding their right to conduct meetings without staff. Additionally, a social service staff member acknowledged their unawareness of this policy and indicated a need to review it.
Ombudsman Contact Information Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the ombudsman's contact information was accessible and visible to residents, which interfered with their rights to communicate and access the state's ombudsman office. During an interview with nine resident council members, it was revealed that they were unaware of who the ombudsman was, their purpose, or where to find that information. An observation showed that the ombudsman's contact information was posted on an information board by the long-term care halls, but it was written in small print and displayed out of view for residents utilizing a wheelchair. Additionally, there was no information board located on the skilled halls, further limiting access to this important information for residents.
Failure to Distribute Mail on Weekends
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, resulting in a deficiency. On July 17, 2024, at 11:22 a.m., nine members of the resident council reported that mail was not distributed on weekends. At 11:24 a.m., the social services staff confirmed that while mail was delivered on Saturdays, it was not distributed to residents until Monday. This affected the 101 residents residing in the facility, as identified by the Director of Nursing (DON).
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were readily accessible and available to residents and visitors. During an observation and interview on July 17, 2024, at 11:28 a.m., nine resident council members stated they did not know where the state inspection book was located. Additionally, at 11:43 a.m., a sign was observed on the information board in the long-term care halls indicating that survey results could be found at the front desk. However, there was no sign or mention of the survey results in the skilled halls.
Failure to Ensure Anonymous Grievance Filing and Identification of Grievance Official
Penalty
Summary
The facility failed to ensure that residents and their representatives could file grievances anonymously and were informed about the grievance official. The grievance policy, dated February 2024, stated that the health center would provide a mechanism for filing grievances without fear of retaliation and would inform residents and their representatives about the grievance process and the designated grievance official. However, during an interview on July 17, 2024, resident council members expressed that they were unaware of how to file a grievance, relying instead on staff to address their issues. Additionally, social services staff were uncertain about the identity of the grievance official, indicating a lack of communication and implementation of the grievance policy.
Delay in Care for Fractured Finger
Penalty
Summary
The facility failed to provide timely care to a resident with a fractured finger. The resident, who had diagnoses including parkinsonism and pain, experienced a fall and complained of pain in their right hand. An x-ray confirmed an acute fracture in the right proximal phalanx of the fourth finger. A physician's order was given for ice pack application four times daily and an orthopedic hand specialist referral was made. However, the resident was not seen by any provider until nearly a month later, and the orthopedic consultation did not occur until over two months after the fall. The delay in care was acknowledged by an LPN, who stated that the appointment was not set up and should have been followed up to prevent the delay. The DON confirmed the delay in care and stated that the interventions during the period included ice packs and Tylenol as needed for pain.
Failure to Document Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails for two residents. Resident #4, who had a fracture of the right lower leg and required extensive assistance with transfers, was observed with bed rails in use without any documented assessment, physician's order, or informed consent. Despite the resident using the rails for positioning since January, the necessary documentation was not found, as confirmed by the LPN and the Director of Quality. Similarly, Resident #19, admitted with hemiplegia and hemiparesis and severe cognitive impairment, had been using bed rails since admission without any documented assessment, physician's order, or informed consent. The DON confirmed the absence of these critical documents, indicating a failure in the facility's adherence to its own bed rail policy and procedure.
Deficiencies in Food Storage, Handling, and Sanitization Practices
Penalty
Summary
The facility failed to adhere to its policies regarding food storage, handling, and sanitation, leading to multiple deficiencies. Observations revealed that food items such as tater tots, chicken tenders, and bread were not labeled, dated, or stored according to the facility's policy. Additionally, a bowl of sausages was found uncovered on the counter. The facility's policy required that all food items be covered, labeled, and dated, which was not followed. Furthermore, the temperature of bacon was recorded at 125 degrees Fahrenheit, below the required 135 degrees Fahrenheit for hot food service, indicating improper food handling practices. The facility also failed to ensure proper glove use and sanitization practices. Dietary Aide #2 did not change gloves between tasks, such as cracking eggs and handling silverware, contrary to the facility's policy. Additionally, the dishwasher was found without sanitizer solution, preventing the measurement of parts per million (ppm) and compromising dish cleanliness. The facility's policy required a sanitizer solution concentration of 50-100 ppm sodium hypochlorite. Moreover, there was a failure to document hot food temperatures as required by the facility's guidelines, further indicating lapses in adherence to food safety protocols.
Inaccessible Call Devices in Memory Care Unit
Penalty
Summary
The facility failed to ensure that call devices were accessible to residents in the memory care unit, affecting two residents. One resident, diagnosed with dementia and heart failure, was observed with the call light cord hanging over the head of the bed, making it inaccessible. Another resident, with diastolic heart failure and Alzheimer's disease, was found with call light cords hanging over the foot of an empty bed, also out of reach. A CNA confirmed that the call light cords were not within reach for both residents. The Director of Nursing acknowledged that call devices should be within reach at all times.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote resident dignity by not adhering to its policy regarding meal assistance. A resident with Alzheimer's disease, who was severely cognitively impaired and required supervision or touching assistance with eating, was observed being assisted by an LPN while the LPN was standing. This occurred on two separate occasions during the same meal period. The facility's policy mandates that staff should be seated when assisting residents with meals. The LPN acknowledged standing while assisting the resident and confirmed that this was against the facility's policy. The Director of Nursing also stated that staff should be seated when assisting residents with meals.
Failure to Obtain Physician Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident had a physician order and an assessment to self-administer medications. This deficiency was identified during an observation where a bottle of saline nasal spray was found on the nightstand of a resident, who stated they self-administered the spray at night. Upon review, there was no documentation of a physician's order or an assessment for the resident to self-administer the nasal spray. An LPN confirmed that the resident did not have the necessary physician order or assessment. The Director of Nursing acknowledged that a self-administration evaluation and physician order were required for medications kept at the bedside.
Inaccurate MDS Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete a quarterly assessment for a resident, leading to a deficiency in the accurate completion of Minimum Data Set (MDS) assessments. The resident, who was admitted with diagnoses including parkinsonism and a psychotic disorder with hallucinations, had a physician's order to receive 34 mg of Nuplazid, an antipsychotic medication, at bedtime. However, the admission assessment incorrectly documented that the resident had not received antipsychotic medications, despite the February Medication Administration Record (MAR) showing that Nuplazid had been administered daily during the look-back period. This discrepancy was confirmed by the MDS Coordinator, who acknowledged that the admission assessment was not coded correctly.
Care Plan Deficiency: Bed Rail Use Not Documented
Penalty
Summary
The facility failed to ensure that the care plans for two residents were revised to include the use of bed rails, as required by their policies. Resident #4, who had a diagnosis of a fracture of the right lower leg and required assistance with personal care, was observed with two bed rails up on each side of the head of the bed. However, the care plan for Resident #4 did not document the use of these bed rails. MDS Coordinator #2 confirmed that the use of positioning rails was not documented in the care plan, although it should have been. Similarly, Resident #19, who was admitted with diagnoses of hemiplegia and hemiparesis, had bed rails in use since admission. Despite this, the care plan for Resident #19 also failed to document the use of bed rails. The DON acknowledged the presence of bed rails since admission, and MDS Coordinator #2 confirmed the omission in the care plan documentation.
Failure to Maintain Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders regarding the maintenance of oxygen equipment for a resident with chronic respiratory failure and chronic obstructive pulmonary disease. The physician's order, dated April 10, 2024, specified that the nasal cannula should be changed, and the concentrator filters should be cleaned and dried once a week. However, on July 15, 2024, it was observed that the oxygen tubing on the concentrator was last changed on June 24, 2024, and the tubing on the portable tank was last changed on June 3, 2024. Additionally, the concentrator filters had visible dust buildup. An LPN confirmed that the tubing and filters were not changed or cleaned as ordered, despite the facility's policy requiring weekly changes.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information, including 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. During a tour of the memory care unit on 07/15/24, it was observed that a plastic note holder outside the nurses' station contained a daily assignment sheet listing staff members for the 7:00 a.m. to 3:00 p.m. shift, but it lacked the resident census and actual hours worked. Additionally, no RNs were listed on the page. Similar observations were made on 07/17/24, where assignment sheets on each unit also lacked the required information. On 07/19/24, the AIT confirmed that the hours worked were not included on the sheets and that the census was not documented, although RNs were present in the building.
Infection Control Breach in Handling Wet Linens
Penalty
Summary
The facility failed to maintain proper infection control procedures while handling wet linens. During an observation, a wet cloth bed pad, a wet blanket, a wet gown, and a clear trash bag were found on the floor in a resident's room. A CNA entered the room and picked up the dirty linens without wearing appropriate personal protective equipment (PPE), specifically gloves, and carried the wet linens down the hall without placing them in a bag, allowing them to touch their clothing. The CNA acknowledged that gloves should have been worn when handling soiled linens. The Director of Nursing (DON) confirmed that wet linens should be placed in a bag and not on the floor, and that gloves are required when picking up soiled linens. The facility's infection control policy and PPE use policy emphasize the importance of using PPE to prevent the spread of infections, particularly when there is potential exposure to blood, bodily fluids, or pathogens.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to ensure that a facility-wide assessment was updated annually, as required. The last documented update of the Facility Assessment Tool was on November 21, 2017, and the review with the Quality Assurance and Performance Improvement (QAA/QAPI) committee was on December 13, 2017. During an interview on July 19, 2024, the Administrator acknowledged that the facility assessment should be updated annually and stated that their process involved changing any information that required updating. However, upon review, it was confirmed that the facility assessment had not been updated since 2017, despite the presence of 101 residents in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Health Center At Concordia | 0.4 mi | ★★★★★ | 0 | 0 |
| St. Ann's Skilled Nursing And Therapy | 0.5 mi | ★★★★★ | 1 | 0 |
| The Lakes | 2.1 mi | ★★★★★ | 0 | 0 |
| Heritage At Brandon Place Health & Rehabilitation | 2.8 mi | ★★★★★ | 5 | 0 |
| Warr Acres Nursing Center | 2.9 mi | ★★★★★ | 0 | 0 |
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