Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Garland Road Nursing & Rehab Center during CMS and state inspections, most recent first.
A deficiency was cited when the facility failed to maintain comprehensive care plans for two residents: one with severe cognitive impairment and documented moderate elopement risk, and another with end stage renal disease who was dependent on staff for all transfers and required a mechanical lift. After a change in EHR systems, an existing care plan addressing exit-seeking behaviors was not carried over, and no elopement focus or interventions were present in the active care plan despite multiple elopement risk assessments. This resident subsequently left the building and was later found off premises with scratches. In a separate case, a resident who required a mechanical lift for transfers had no transfer-related focus or interventions in the care plan, and during a lift transfer the sling strap broke, causing a fall that resulted in fractures to the leg and clavicle. CNAs reported they did not have direct access to care plans and relied on nurses for information, while leadership acknowledged that residents at elopement risk and those needing lift assistance should have been care planned accordingly.
A resident who was cognitively intact, had end-stage renal disease, lower extremity impairments, and was dependent for all transfers fell from a mechanical lift when a sling strap broke during a bed-to-wheelchair transfer. A CNA had retrieved a white sling from the laundry, guessed at the size, reported no training on sling sizing, and did not know the sling was disposable; the sling broke on one side during the transfer, and the resident sustained fractures and reported pain, embarrassment, and fear of transfers. At the time of the incident, the resident’s care plan did not include a transfer focus or interventions, despite facility policies requiring safe transfer techniques and sling inspection. In a separate incident, another resident with severe cognitive impairment, dementia with behavioral disturbances, and chronic kidney disease, who had been repeatedly assessed as a moderate elopement risk and was known by staff to watch doors and exit seek, eloped from the building after another resident let them out and was later found off premises with scratches. Due to a change to a new EHR, this resident’s prior elopement care plan focus and interventions were not carried over, and the DON acknowledged that the care plan was not updated after elopement risk assessments, leaving the resident without an active care plan focus or interventions addressing elopement risk and increased supervision until after the elopement occurred.
A resident with dementia and significant cognitive impairment repeatedly wandered into other residents' rooms and beds, sometimes becoming violent when redirected. Despite multiple documented incidents and staff awareness, the care plan was not updated with new interventions beyond redirection, and the interdisciplinary team did not meet to address the ongoing behavior.
A resident with heart failure and atrial fibrillation missed several prescribed doses of an antibiotic and an antihypertensive, and later had an elevated heart rate. There was no documentation that the physician was notified of the missed antibiotic doses or the abnormal heart rate, as confirmed by staff interviews and record review.
Three residents who required assistance with bathing did not receive scheduled showers as documented, with multiple missed dates and inconsistent or absent documentation of refusals. Residents reported extended periods without showers, and staff interviews revealed gaps in documentation and adherence to shower schedules, despite facility policy and expectations.
Two residents did not receive medications as ordered, including insulin, magnesium oxide, ciprofloxacin, and metoprolol. Staff were unable to explain documentation marks or provide consistent reasons for missed or held doses, and one resident reported not always receiving requested medications. Interviews revealed confusion among staff regarding medication administration procedures and documentation.
A resident receiving sliding scale insulin for type 2 diabetes mellitus did not have the amount of insulin administered documented in the medication administration record, despite physician orders specifying dosing based on blood sugar levels. Staff interviews indicated that the electronic health record system may not have allowed for proper documentation, and the facility was unable to provide records of the insulin doses given.
A resident with intact cognition and chronic health conditions was found to be self-administering fluticasone propionate nasal spray without a physician's order or a documented self-administration assessment. Facility staff confirmed the lack of required documentation and ongoing education, contrary to facility policy.
A resident with type 2 diabetes mellitus experienced a low blood sugar episode, but staff did not document any interventions or a required blood sugar recheck as per facility policy. The medication administration record showed insulin was held, but there was no evidence that hypoglycemia treatment was provided or that follow-up monitoring occurred.
Two residents did not receive accurate MDS assessments: one resident undergoing regular dialysis was not documented as receiving dialysis in multiple MDS assessments, and another resident who was edentulous was incorrectly recorded as having natural teeth. Staff interviews and record reviews confirmed these inaccuracies, with the MDS coordinator attributing the errors to missed verification and lack of direct assessment.
A resident received wound care and topical medication without a physician's order or routine assessments, and medication was kept at the bedside. Another resident receiving hospice care had an order for oxygen therapy documented by hospice, but this was not reflected in the facility's physician orders due to communication lapses between facility staff and hospice. Both residents were cognitively intact at the time of the deficiencies.
Staff did not consistently follow infection control protocols, including failure to wear gloves during wound care, improper glove changes and hand hygiene during peri-care for a dependent resident, lack of infection trend identification over several months, and improper handling and labeling of respiratory equipment such as nebulizers and oxygen tubing.
A resident with intact cognition was found with a box of triple antibiotic ointment at their bedside, marked by an LPN as 'may keep at bedside,' without a required assessment or physician's order for self-administration or bedside storage. Both the LPN and DON confirmed that facility policy requires an assessment and physician's order, but neither was present in the resident's record.
A resident with no natural teeth and a Medicaid payer source did not receive required dental services, including assessment and provision of dentures, after admission. The resident reported pain, discomfort, and difficulty eating, and staff confirmed that dental care was not arranged as required by facility policy.
A resident's room was found to have a strong urine odor, which was confirmed by a CNA, an LPN, and the DON, all of whom stated that the smell did not support a homelike environment. The odor was attributed to the resident's incontinence and the condition of the floor and bathroom, in violation of the facility's cleaning policy.
A resident receiving oxygen therapy had one tank properly secured and another left loose and leaning against the wall in their room, contrary to facility policy requiring oxygen cylinders to be locked and secured in a designated storage area. Staff confirmed the tanks should have been stored in the oxygen room and properly secured.
Failure to Develop Comprehensive Care Plans for Elopement Risk and Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents identified as being at risk for elopement and for residents requiring mechanical lift assistance for transfers. For one cognitively impaired resident with a BIMS score of 2 and diagnoses including schizophreniform disorder and chronic kidney disease, two elopement risk assessments dated 08/19/25 and 11/20/25 identified the resident as a moderate elopement risk, with scores of 19 and 16 respectively. Despite these assessments, the resident’s active care plan in the current EHR did not include elopement as a focus and contained no interventions addressing elopement risk from 06/12/25 through 12/10/25. The facility’s own Elopement Management policy required updating the care plan in the EHR, and the Comprehensive Care Plans policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes based on the comprehensive assessment. The cognitively impaired resident had a prior care plan in a previous EHR, dated 02/06/25, that included a focus on exit seeking and interventions such as analyzing key times and triggers, encouraging activities, frequent visual checks, maintaining a behavior log, and providing a pleasant home-like environment. However, this prior care plan was in an EHR that was no longer active and not accessible to staff after the facility changed systems earlier in the year. The DON acknowledged that the old focus and interventions were never carried over to the new EHR and that the care plan was not updated after the elopement assessments showed the resident was a moderate elopement risk. On 12/09/25, the resident eloped from the facility after another resident admitted to letting them out; the resident was discovered missing at 6:00 p.m., and a search was initiated with notification of family and police. The resident was later found near a church north of the building with scratches on the elbow and returned to the facility. The deficiency also includes the facility’s failure to develop a comprehensive care plan for a resident who required assistance with transfers using a mechanical lift. This resident had intact cognition with a BIMS score of 15 and was admitted with end stage renal disease. The quarterly assessment dated 07/23/25 documented lower extremity impairments and dependence on staff for dressing, toilet hygiene, and all transfers. Despite this level of dependence, the resident’s care plan, prior to 12/22/25, did not contain any focus or interventions related to transfers or the use of a mechanical lift. On 12/16/25, during a transfer from bed to wheelchair using a mechanical lift with two aides present, the sling strap broke on one side, and the resident fell from approximately three feet, sustaining a left tibia fracture and a right clavicle fracture. The resident reported significant pain, the need for staff to feed them, embarrassment, use of a leg brace, and fear of transfers. Both the corporate nurse and the DON confirmed that residents requiring a lift to transfer should have transferring included in the care plan and that this resident’s care plan lacked any transfer-related focus or interventions prior to 12/22/25. In addition, staff access and reliance on care planning information contributed to the deficiencies. CNA #2 stated they did not have access to the care plan and instead relied on nurses and fellow aides to learn about residents at risk for elopement and other care needs, noting that their charting system did not provide all details. This lack of direct access to care plans for direct care staff, combined with the failure to migrate or update critical care plan information in the new EHR, resulted in the absence of documented, comprehensive care plans addressing elopement risk for the cognitively impaired resident and transfer assistance for the resident dependent on a mechanical lift. The facility’s own policies requiring updated, comprehensive care plans were not followed in these instances, leading to the identified deficiencies.
Removal Plan
- Residents with an elopement score greater than 11 should have interventions in their care plan.
- The DON or designee will in-service all clinical licensed staff on completion of elopement risk assessment; staff unable to complete education will not be allowed to work until education is completed.
- An audit of all residents' elopement assessments will be completed.
- The DON or designee will update all care plans for residents identified as a moderate or high elopement risk.
- The DON or designee will monitor elopement risk assessment completion quarterly with the MDS assessment completion and update the care plans.
- The DON would track, trend, and analyze audit results and forward to the QAPI committee.
Unsafe Mechanical Lift Transfer and Inadequate Elopement Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a dependent resident using a mechanical lift and failure to provide adequate supervision to prevent elopement for another resident. One resident with intact cognition, end-stage renal disease, lower extremity impairments, and dependence on staff for all transfers was being transferred from bed to wheelchair with a mechanical lift when the sling strap broke, causing the resident to fall. The resident’s quarterly assessment documented dependence for all transfers, but the care plan dated shortly after the incident did not contain a focus or interventions for transfers at the time the accident occurred. The facility’s transfer policy required staff to provide safe, effective transfer techniques and to utilize manufacturer guidelines for mechanical lifts, and a facility document on sling care required inspection of slings for wear, tears, and loose stitching after laundering. During the transfer incident, a CNA reported going to the laundry room to obtain a sling because the resident’s usual blue sling was not available in the room. The CNA stated that slings in the laundry came in different sizes and that they selected a medium white sling based on their own judgment, guessing the size and not usually checking for sizes. The CNA further stated they had never been trained on how to determine sling size, did not know the white slings were disposable, and did not understand why such slings were hanging in the laundry room. While two aides were transferring the resident with the mechanical lift, the white sling broke on one side, and the resident fell from approximately three feet in the air, landing on the back of the head, both shoulders, both hips, and the left knee, and later being diagnosed with fractures of the right clavicle and left tibia. The resident reported experiencing significant pain, needing staff assistance with feeding due to the clavicle fracture, and feeling embarrassed and fearful of transfers. The deficiency also includes failure to provide adequate supervision to prevent elopement for another resident with significantly impaired cognition, dementia with behavioral disturbances, and chronic kidney disease. This resident had been assessed twice as a moderate elopement risk, with elopement assessment scores of 19 and 16, and had a prior care plan focus for exit-seeking behavior that included interventions such as frequent visual checks, maintaining a behavior log, and analyzing triggers. However, after the facility implemented a new EHR system, the DON acknowledged that the existing elopement focus and interventions from the earlier care plan were not carried over, and the care plan was not updated following the elopement risk assessments. As a result, from mid-year until after the elopement event, the resident did not have a current care plan focus or interventions addressing elopement risk and increased supervision, despite being known by staff to watch doors and exit seek for several months. The resident subsequently eloped from the facility after another resident let them out, was discovered missing by a CNA, and was later found off premises near a church parking lot with scratches on the arms before being returned. The facility is located on a busy two-lane main street adjacent to a golf course with ponds, and the elopement policy required documentation of incidents, nursing notes with accurate accounts of situations and outcomes, social services notes addressing emotional aspects, updated elopement risk assessments, and updated care plans. In the elopement case, a facility incident report documented that the resident was missing and later found during a search, and nursing notes recorded that the resident was discovered missing, that another resident admitted to letting them out, and that the resident was located and returned with scratches. However, the care plan revision following the elopement added a focus for elopement risk and some interventions such as staff awareness in common areas, redirection when fixated on exits, and signage on exits, but did not include interventions for increased supervision compared to the earlier care plan. The DON confirmed that the facility did not follow its policy to update the care plan after the elopement assessments showed the resident was a moderate elopement risk, resulting in a period where the resident’s known exit-seeking behavior and risk were not addressed in the active care plan.
Removal Plan
- Send Resident #7 to the hospital and return to the facility for continued treatment.
- Update Resident #7's care plan with interventions and focus to include transfers.
- Have the DON or designee perform audits of residents who require assistance with transfers using a mechanical lift and update care plans accordingly.
- Have the DON or designee reeducate nursing staff on choosing the proper slings and weight requirement.
- Do not allow staff who did not receive education to work until educated.
- Notify the medical director of the IJ.
- Hold a QAPI meeting with the medical director, the facility administrator, and director of nursing to review the plan of removal.
- Have the director of nursing track, trend, and analyze audit results and forward results of audits monthly to the QAPI Committee for review and/or action.
Failure to Update Care Plan After Repeated Wandering Incidents
Penalty
Summary
The facility failed to update and revise a resident's care plan with appropriate interventions following multiple incidents of wandering into other residents' rooms. Despite repeated episodes where a resident with significant cognitive impairment and a diagnosis of dementia was found in other residents' rooms and beds, the care plan remained unchanged after its initial creation. The only intervention documented was redirection, and there was no evidence of additional or modified strategies being implemented after each incident. Nursing notes and incident reports documented several occasions where the resident entered other residents' rooms, sometimes resulting in altercations or distress to other residents. In one instance, the resident was found asleep in another resident's bed, and in another, the resident became violent when redirected by staff, attempting to hit and bite them. The resident's behavior persisted over several months, with staff and family members being notified of the incidents, but no new interventions were added to the care plan to address the ongoing wandering and associated behaviors. Interviews with staff, including the DON, ADON, and CNAs, confirmed that the only intervention in place was redirection, and that the care plan had not been updated after each incident. The facility lacked a policy for revising care plans following such events, and the interdisciplinary team did not meet to develop new interventions after repeated episodes of wandering. This failure to update the care plan contributed to continued incidents affecting both the resident and others in the facility.
Failure to Notify Physician of Missed Medication Doses and Abnormal Heart Rate
Penalty
Summary
The facility failed to notify the physician when a resident missed prescribed doses of an antibiotic and experienced an abnormal heart rate. Specifically, a resident with diagnoses including congestive heart failure and atrial fibrillation had physician orders for metoprolol succinate and ciprofloxacin hydrochloride. The medication administration record showed missed doses of ciprofloxacin on three occasions and missed doses of metoprolol on two occasions. There was no documentation that the physician was notified of the missed antibiotic doses. Additionally, the same resident received metoprolol with a recorded heart rate of 120 bpm, but there was no documentation that the physician was notified of this elevated heart rate. Interviews with staff confirmed the lack of physician notification for both the missed antibiotic doses and the elevated heart rate. The DON stated that the physician should be notified of missed antibiotic doses and that the physician's preference for notification of elevated heart rate was communicated verbally to staff.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers for three residents who required assistance with bathing, as evidenced by record review and resident and staff interviews. Documentation showed that residents with intact cognition and various medical diagnoses, including hemiplegia, chronic obstructive pulmonary disease, and a history of cerebral infarction, did not receive showers according to their established schedules. For example, one resident was scheduled for showers three times a week but only received a fraction of the expected showers over several months, with multiple dates lacking documentation of either a shower or a documented refusal. Another resident received only one out of five scheduled showers in a given period, and a third resident missed multiple scheduled showers, with documentation inconsistencies regarding refusals. Residents reported going several days without showers, and some stated that refusals were inaccurately documented by staff. Staff interviews confirmed that showers were scheduled and that refusals were to be documented, but there was a lack of resident sign-off on refusal documentation, and some staff acknowledged not seeing showers documented for the missed dates. The DON confirmed the expectation that staff follow resident shower schedules. The facility's policy required staff to provide bathing services within standard practice guidelines, but the records and interviews indicated this was not consistently followed.
Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications as ordered for two of three sampled residents reviewed for medication administration. For one resident with type 2 diabetes mellitus, the medication administration record indicated that insulin glargine was not administered as ordered on a specific date, with staff unable to explain the meaning of the documentation mark used. There was no documentation that the insulin was given, and staff interviews confirmed uncertainty about the record and the process for documenting refusals or missed doses. For another resident with diagnoses including congestive heart failure and atrial fibrillation, there was no documentation that magnesium oxide was administered over a three-week period. Additionally, the medication administration records for ciprofloxacin and metoprolol showed missed or held doses, with staff unable to consistently explain the reasons for these actions or the documentation used. The resident reported sometimes not receiving medications even when requested. Staff interviews revealed confusion about medication parameters, documentation codes, and the process for holding or administering medications, with the DON confirming that some medications were not administered as ordered.
Failure to Document Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to document the amount of sliding scale insulin administered to a resident with type 2 diabetes mellitus who was receiving Humalog insulin according to physician orders. Review of the medication administration records for the resident over multiple date ranges showed that, although blood sugar readings were recorded, there was no documentation of the specific number of insulin units given for blood sugars above 100, as required by the sliding scale orders. The physician's orders provided clear dosing instructions based on blood sugar ranges, but the records did not reflect the actual doses administered. Interviews with the DON and an LPN revealed that staff followed the sliding scale orders, but the electronic health record system may not have provided an option to document the exact amount of insulin administered. The LPN stated that they sometimes entered this information in a note, but acknowledged the importance of having this documentation available for ongoing insulin treatment, interventions, and emergencies. The facility was unable to provide documentation of the insulin doses administered for the dates reviewed.
Failure to Ensure Physician's Order and Assessment for Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including congestive heart failure and chronic obstructive pulmonary disease was observed to have fluticasone propionate nasal spray on their bedside table. The resident reported self-administering the nasal spray once daily, despite a physician's order indicating it should be administered twice daily. Review of facility policy indicated that residents who self-administer medications must have a physician's order and a self-administration assessment, with monthly counseling and documentation. Interviews with facility staff, including an LPN and the DON, confirmed that there was no documented order or assessment for the resident to self-administer the nasal spray. The LPN stated that initial education was provided to the resident regarding the medication, but no ongoing education or assessment was documented. The absence of a physician's order and a self-administration assessment for the medication constituted a failure to follow facility policy and regulatory requirements for medication administration.
Failure to Provide Hypoglycemia Treatment and Documentation
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with low blood sugar as required by physician orders and facility policy. Specifically, a resident with type 2 diabetes mellitus experienced a blood sugar reading of 39, but there was no documentation that the facility staff implemented interventions for hypoglycemia as outlined in the facility's policy, which included administering glucose and rechecking blood sugar within 15 minutes. The medication administration record indicated that insulin was held due to vital sign parameters, but there was no evidence that the resident's blood sugar was rechecked or that any hypoglycemia treatment was provided. Interviews with the ADON confirmed the absence of documentation regarding interventions or a blood sugar recheck for the incident.
Inaccurate MDS Assessments for Dialysis and Oral Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident admitted with end stage renal disease and a displaced lower right leg fracture, physician orders indicated the need for dialysis three times a week since admission. However, multiple MDS assessments, including admission and quarterly assessments, did not document that the resident was receiving dialysis services in section O. The MDS coordinator acknowledged that dialysis was missed in the assessments due to not verifying this information during the look-back period, despite the resident and staff confirming ongoing dialysis treatments. For another resident admitted with diagnoses including alcoholic cirrhosis, chronic hepatic failure, and liver cell carcinoma, the admission assessment inaccurately indicated the presence of natural teeth and did not document the resident as edentulous in section L. Observations and interviews with the resident, LPN, and DON confirmed the resident had no natural teeth upon admission and required dentures. The MDS coordinator stated that the assessment relied on chart reviews rather than a direct visual assessment, leading to the inaccurate documentation of the resident's oral status.
Failure to Obtain Physician Orders and Maintain Communication for Wound and Hospice Care
Penalty
Summary
The facility failed to ensure proper physician orders and routine assessments for wound care and medication administration for a resident with an abrasion. Specifically, a licensed nurse was observed applying mupirocin ointment to a resident's head without a corresponding physician's order, and the medication was kept at the bedside. There were no documented assessments or physician's orders for the abrasion, despite facility policy requiring weekly skin evaluations and care consistent with professional standards. The resident, who had an intact cognitive status, reported that staff applied ointment to the abrasion, and the beauty operator confirmed placing cotton on the wound after it bled during hair washing. The Director of Nursing and LPN were unable to locate any active orders or assessments related to the abrasion or the use of mupirocin. Additionally, the facility did not maintain adequate communication with hospice services regarding another resident's oxygen therapy. An oxygen concentrator and tanks were observed in the resident's room, and hospice documentation indicated an order for oxygen therapy. However, this order was not reflected in the resident's physician orders within the facility. Both the LPN and DON acknowledged the absence of a physician order for oxygen in the facility records, attributing the issue to a communication lapse with hospice. The resident, who was cognitively intact, was unsure how to contact hospice to discuss their care.
Infection Control Lapses in Wound Care, Peri-Care, Surveillance, and Respiratory Equipment Handling
Penalty
Summary
Staff failed to follow infection prevention and control protocols in several instances. An LPN applied mupirocin ointment to the back of a resident's head without wearing gloves, despite facility policy requiring standard precautions for wound care. The resident had an intact cognitive status, as indicated by a BIMS score of 15. The LPN stated they did not use gloves because they preferred frequent handwashing over using alcohol gel. During peri-care for a resident with severe cognitive impairment and total incontinence, two CNAs did not change gloves after cleaning the resident and before handling clean linen. One CNA placed soiled linen on the floor and did not perform hand hygiene after removing gloves, subsequently entering another resident's room and assisting with a shower without hand hygiene. Facility policy required glove changes and hand hygiene at specific points during care, which were not followed. The IP acknowledged these lapses and noted that soiled linen should not be placed on the floor. The facility also failed to identify infection trends over three months, despite having infection control logs showing multiple cases of skin infections and UTIs. The IP admitted to not identifying trends as required by policy. Additionally, respiratory equipment for a resident was not properly bagged, labeled, or dated, with a nebulizer mouthpiece left unbagged and moist on a bedside table and oxygen tubing lacking a date. Staff confirmed that infection control policies for respiratory equipment were not followed in these instances.
Failure to Assess and Obtain Physician Order for Bedside Medication Storage
Penalty
Summary
A resident was observed with a medication box of triple antibiotic ointment at their bedside, with a handwritten note stating 'may keep at bedside.' The resident had an intact cognitive status, as indicated by a BIMS score of 15 on their most recent assessment. However, there was no documented assessment or physician's order in the clinical record authorizing the resident to self-administer medication or to keep medication at the bedside, as required by facility policy. The policy specifies that bedside medication storage is only permitted for residents who are able to self-administer medications, upon written order of the prescriber and after an interdisciplinary assessment. During interviews, the resident stated that a nurse applied the ointment because it was difficult for them to do so. The LPN confirmed that they had written the note on the medication box and acknowledged that a physician's order was required for bedside medication storage, but could not locate such an order for this resident. The DON also confirmed that an assessment and physician's order were necessary and that neither was present for this resident. These findings indicate that the facility failed to assess the resident for self-administration of medication and did not obtain the required physician's order.
Failure to Provide Dental Services to Medicaid Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was admitted with no natural teeth and had a Medicaid payer source. According to facility policy, oral healthcare and dental services should be provided to each resident, with social services responsible for making dental appointments. However, the resident did not receive any dental services from admission through the time of the survey, and the social services director acknowledged that the resident was missed for dental care setup after transitioning from skilled care to long-term care. The resident, who had diagnoses including alcoholic cirrhosis of the liver, chronic hepatic failure, and liver cell carcinoma, reported having no natural teeth, experiencing pain and discomfort in the mouth, and difficulty eating certain foods. The resident expressed a need for dentures and stated that dental services were never offered. Staff interviews confirmed the resident was edentulous since admission and had not received dental care, despite being eligible through Medicaid.
Failure to Maintain Odor-Free Resident Room
Penalty
Summary
The facility failed to maintain a resident's room free from odors, specifically a strong urine smell, as observed in room 217. During the survey, the odor was confirmed by direct observation and acknowledged by a CNA, an LPN, and the Director of Nursing, all of whom identified the smell as urine and attributed it to the resident's incontinence and the condition of the floor and bathroom. The facility's policy on resident room cleaning, which emphasizes providing a clean, attractive, and safe environment, was not followed in this instance. Staff interviewed agreed that the odor did not facilitate a homelike environment and did not meet the facility's standards for cleanliness.
Improper Storage of Oxygen Tanks
Penalty
Summary
The facility failed to ensure safe storage of oxygen tanks for one resident who was receiving oxygen therapy. During observations, one oxygen tank was found properly secured to a cart with a strap, while another tank was left loose and leaning against the wall in the resident's room. Facility policy requires all oxygen cylinders to be stored in a fire safety closet, locked, and secured with a non-combustible strap or chain to prevent tipping. Staff interviews confirmed that oxygen tanks should be stored in the designated oxygen room and secured according to policy. The resident involved had a history of cirrhosis of the liver and nonalcoholic steatohepatitis, was on hospice care, and required oxygen as needed for respiratory comfort, with intact cognition as per recent assessment.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Enid
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Commons | 1.4 mi | ★★★★★ | 0 | 0 |
| Baptist Village Of Enid | 3.1 mi | ★★★★★ | 2 | 0 |
| Greenbrier Village Health And Rehabilitation | 4.7 mi | ★★★★★ | 0 | 0 |
| The Living Center | 5 mi | ★★★★★ | 0 | 0 |
| Enid Senior Care | 6 mi | ★★★★★ | 0 | 0 |
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