Garland Road Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Enid, Oklahoma.
- Location
- 1404 North Garland Road, Enid, Oklahoma 73703
- CMS Provider Number
- 375527
- Inspections on file
- 26
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 9 (2 serious)
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.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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