Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Parkland Manor Living Center during CMS and state inspections, most recent first.
A resident’s level I PASRR screen listed only cardiac diagnoses and indicated no serious mental illness, even though the admission record showed schizoaffective disorder, bipolar type, and bipolar disorder. The administrator stated the PASRR form was not completed correctly and there was no documentation that OHCA had been notified of the serious mental illness diagnosis.
Failure to change oxygen tubing per policy: A resident with COPD, asthma, and SOB received oxygen by NC PRN, but the tubing had no date showing when it was last changed. The facility policy required oxygen cannulae and tubing to be changed every 7 days or as needed, yet an LPN stated PRN oxygen tubing was changed only as needed, while the DON stated it should be changed weekly.
A resident with pneumonitis and dysphagia was transferred to the hospital twice without timely notification to their legal guardian. The facility contacted a secondary emergency contact instead, delaying the notification to the legal guardian, contrary to the facility's policy.
A facility failed to properly administer and document medications for residents, resulting in discrepancies in medication counts and unavailability of prescribed medications. A resident with DIC, pneumonia, and sepsis did not receive hydromorphone and lorazepam as ordered, with discrepancies noted in the count sheets. Another resident with multiple sclerosis and trigeminal neuralgia experienced issues with morphine administration due to leaking bottles and unavailable medication. The facility's policies on medication handling and documentation were not effectively implemented, leading to these deficiencies.
The facility failed to ensure accurate Level I PASARR assessments for three residents, resulting in unreported serious mental illness diagnoses. A resident with schizoaffective disorder and other mental health conditions was incorrectly documented as having no serious mental illness. Another resident with bipolar disorder and a third with schizoaffective and major depressive disorders were similarly misreported. The DON confirmed the errors and the lack of notification to the OHCA.
A facility failed to ensure a resident was free from accident hazards due to improper use of a mechanical lift. A resident reported that typically one person uses the lift to transfer her, although documentation indicated a two-person assist was required. A CNA admitted to transferring the resident by himself, contrary to the facility's policy that requires two staff members for all transfers.
A facility failed to follow its policy for administering medications through a PEG tube for a resident with dementia and cerebral infarction. An LPN did not verify the tube's placement before administering water and mixed 12 medications together instead of administering them separately. The DON confirmed that the nurse should have verified the tube's placement and administered each medication separately.
Two residents in a long-term care facility received incorrect medications due to staff errors. A resident with diabetes was given Novolog insulin instead of the prescribed Humalog, while another resident with chronic pain received a lower strength of hydrocodone-acetaminophen than ordered. These incidents were identified through observation and confirmed by the DON.
The facility failed to comply with regulations for psychotropic medications, including not limiting PRN use to 14 days and not attempting gradual dose reductions. A resident received lorazepam daily without a 14-day stop date, and another was on multiple psychotropic drugs without GDR attempts or appropriate diagnoses. The DON acknowledged these oversights.
The facility's medication error rate was 6.45%, exceeding the acceptable limit of 5%. An LPN administered the wrong type of insulin to a diabetic resident, and a CMA gave a lower strength of hydrocodone-acetaminophen to a resident with chronic pain. The DON was informed of these errors.
The facility failed to remove expired medications and supplies from storage areas, including a medication cart and treatment cart. An LPN administered insulin to a resident with type II diabetes from a vial opened beyond the recommended 30-day period, unaware of the proper protocol. The DON confirmed the insulin should have been disposed of after 30 days.
A facility failed to accurately code an MDS assessment for a resident with an indwelling catheter. Despite a physician's order to discontinue the catheter, the quarterly MDS assessment incorrectly documented its presence. The DON confirmed the catheter was discontinued and acknowledged the error.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in meeting their care needs. A resident with bipolar disorder did not have a timely AIMS assessment, while another with fractures lacked required safety equipment. Two residents' care plans omitted critical diagnoses. The DON confirmed these oversights.
A facility failed to follow a physician's orders for a resident with fractures and a history of falling. The orders required elevating leg rests and pressure offload boots when out of bed, but observations showed the resident without these aids in place. The DON confirmed the non-compliance.
The facility failed to ensure the consulting pharmacist identified irregularities with psychotropic medications for two residents. One resident received lorazepam frequently without a documented rationale for extending its use beyond 14 days, while another resident had multiple psychotropic medications without any documented attempts at gradual dose reduction or physician rationale. The DON acknowledged these oversights during monthly medication reviews.
Inaccurate PASRR Screening for Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of a level I PASRR assessment for Resident #3. The resident’s medical record showed diagnoses of schizoaffective disorder, bipolar type, and bipolar disorder on the admission diagnosis report, but the level I PASRR screen listed only chronic diastolic congestive heart failure and atherosclerotic heart disease as the primary and secondary diagnoses and indicated there was no diagnosis of a serious mental illness. During interview, the administrator reviewed the PASRR form and the admission diagnoses and stated the level I PASRR form was not completed correctly, and there was no documentation that OHCA had been notified of the serious mental illness diagnosis.
Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to change oxygen tubing per its policy for one resident receiving respiratory care. Resident #30 had diagnoses including COPD, asthma, and shortness of breath, and the care plan documented altered respiratory status and oxygen therapy as ordered. The resident’s quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and a physician order dated 11/10/25 ordered oxygen by nasal cannula every eight hours as needed to keep oxygen saturation above 90%. During observation on 12/02/25, Resident #30 was seen in the room using oxygen by nasal cannula, and there was no date on the oxygen tubing to show when it had last been changed. The facility’s respiratory infection prevention policy stated that oxygen cannulae and tubing should be changed every seven days or as needed. The resident stated they used oxygen only as needed and did not know when the tubing had last been changed. An LPN stated that residents who used oxygen all the time had tubing changed weekly, while some residents who used oxygen as needed had tubing changed only as needed, and that this resident’s tubing was changed only as needed because the resident did not use oxygen all the time. The DON later stated the tubing should be changed every seven days and that the resident should have a physician order for weekly tubing changes.
Failure to Notify Legal Guardian of Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure timely notification of a resident's legal guardian when the resident experienced a change in condition. The facility's policy mandates that the resident's representative be notified within twenty-four hours of a change in the resident's medical or mental condition, except in medical emergencies. However, in the case of a resident with pneumonitis and dysphagia, the facility did not adhere to this policy. The resident was transferred to the hospital on two separate occasions, and in both instances, the legal guardian was not promptly informed. On the first occasion, the resident was transferred to the hospital, and the facility contacted the secondary emergency contact instead of the legal guardian. A message was left for the legal guardian the following day. On the second occasion, the resident was again transferred to the hospital, and the legal guardian was not informed until several hours later. The facility's administrator and DON acknowledged the oversight, noting that the secondary contact was informed because they lived closer and visited the resident daily.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper administration and documentation of medications for residents, leading to discrepancies in medication counts and unavailability of prescribed medications. Resident #2, who had diagnoses including DIC, pneumonia, and sepsis, was prescribed hydromorphone and lorazepam for pain and anxiety. However, the medication administration record did not document the administration of these medications as ordered, and there were discrepancies in the count sheets. The count sheets showed corrections and scribbling, which were not legally appropriate, and the medications were not administered at the scheduled times. Resident #4, diagnosed with multiple sclerosis and trigeminal neuralgia, had a physician order for morphine to be administered sublingually for pain and shortness of breath. The count sheet for Resident #4's morphine showed a discrepancy, with the count going from four to zero, and the medication was not available in the medication cart. Staff reported issues with medication bottles leaking, leading to count corrections, and the facility had begun transitioning to syringes to address this issue. However, the prn morphine was not available for administration when needed. The facility's policies on medication handling, storage, and documentation were not effectively implemented, leading to these deficiencies. Staff were not adequately trained on maintaining accurate medication counts and ensuring the availability of medications. The DON acknowledged that the facility had issues with medication documentation and administration, and corrective actions were not effectively communicated to all staff members involved.
Inaccurate PASARR Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Level I PASARR assessments for three residents, leading to deficiencies in reporting serious mental illness diagnoses. Resident #10's Level I PASARR screen, dated 04/27/23, incorrectly documented no serious mental illness despite the resident having diagnoses of schizoaffective disorder-bipolar type, delusional disorders, and brief psychotic disorders as per a medical diagnosis report dated 05/01/23. The Director of Nursing (DON) confirmed that the form was not completed correctly and that the Oklahoma Health Care Authority (OHCA) had not been notified of these diagnoses. Resident #8 was admitted with a diagnosis of bipolar disorder, yet their PASARR Level I, dated 10/28/21, incorrectly documented no mental health diagnosis. Similarly, Resident #13, admitted with schizoaffective disorder and major depressive disorder, had a PASARR Level I, dated 10/25/22, that also failed to document any mental health diagnosis. The DON acknowledged that these PASARR forms were not filled out correctly and that the OHCA was not notified.
Improper Use of Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards due to improper use of a mechanical lift. A resident reported that typically one person uses the lift to transfer her, although the monthly summary indicated that a mechanical lift with a two-person assist was required. During an interview, a CNA confirmed that he usually transfers the resident with the mechanical lift and admitted to transferring the resident by himself the previous morning. The Director of Nursing stated that the mechanical lift should always be used by two staff members for all transfers.
Failure to Verify PEG Tube Placement and Administer Medications Separately
Penalty
Summary
The facility failed to adhere to its policy on administering medications through an enteral tube, specifically for a resident with a PEG tube. The policy, revised in November 2018, requires verification of the feeding tube's placement before administering any feeding or medications, and mandates that each medication be administered separately with a flush of 15 mL warm water between medications. However, during an observation, an LPN did not verify the PEG tube's placement before administering 30 mLs of water and subsequently mixed 12 routine medications together in one 30 mL medication cup for administration. The resident involved had diagnoses including dementia, cerebral infarction, and gastrostomy, and was documented as severely cognitively impaired with no swallowing concerns. The resident received 25% or less of their total calories through parenteral or tube feeding. The LPN admitted to not checking the PEG tube's placement using auscultation prior to administering the medications and acknowledged that the medications should have been administered separately. The DON confirmed that the nurse should have verified the PEG tube's placement and administered each medication separately as per the facility's policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for two residents. Resident #5, who had a diagnosis of type II diabetes mellitus, was prescribed Humalog insulin to be injected subcutaneously before meals. However, on May 29, 2024, LPN #2 administered Novolog insulin instead of the prescribed Humalog insulin. This discrepancy was identified when the Director of Nursing (DON) was informed of the incident, confirming that the wrong type of insulin was administered, which did not align with the physician's order. Similarly, Resident #1, who had a diagnosis of chronic pain, was prescribed hydrocodone-acetaminophen 7.5/325 mg to be taken orally every four hours as needed for pain. On May 30, 2024, CMA #1 administered a lower strength of the medication, specifically 5/325 mg, instead of the prescribed 7.5/325 mg. This error was acknowledged by CMA #1 upon review of the Medication Administration Record (MAR) and was later confirmed by the DON. Both incidents highlight a failure to adhere to the facility's medication administration policy, which emphasizes verifying the medication against the MAR to ensure the correct drug, dosage, and administration route.
Failure to Adhere to Psychotropic Medication Regulations
Penalty
Summary
The facility failed to adhere to regulations regarding the use of psychotropic medications for residents. Specifically, a resident with schizoaffective disorder, paranoid personality disorder, and anxiety was prescribed lorazepam as needed for anxiety, which was administered daily over 29 occasions without a 14-day stop date. The Director of Nursing (DON) acknowledged that the medication should have been discontinued after 14 days and reassessed by a physician before reordering. This oversight indicates a failure to limit PRN psychotropic medication use to 14 days as required. Additionally, another resident with dementia, anxiety, and major depressive disorder was prescribed multiple psychotropic medications without any documented attempts at a gradual dose reduction (GDR) or physician's rationale for the continued use of these medications. The consulting pharmacist did not recommend a GDR during monthly reviews, and the DON confirmed that no GDR attempts were made. Furthermore, the use of olanzapine for anxiety was deemed inappropriate by the DON. A third resident with dementia and anxiety was prescribed olanzapine for agitation and anxiety, but the PRN order lacked a 14-day stop date, and the diagnoses were not appropriate for the medication prescribed.
Medication Error Rate Exceeds 5% Due to Incorrect Insulin and Pain Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.45%. During observations, two errors were identified out of 31 medication administration opportunities. The first error involved a resident with type II diabetes mellitus who was prescribed Humalog insulin to be administered before meals. However, an LPN administered Novolog insulin instead, which was not the correct type as per the physician's order. The second error involved a resident with chronic pain who was prescribed hydrocodone-acetaminophen 7.5/325 mg to be taken every four hours as needed. A CMA administered a lower strength of 5/325 mg instead. Upon review, the CMA acknowledged the mistake, confirming that the wrong strength was given. The DON was informed of both errors and acknowledged the discrepancies in medication administration.
Expired Medications and Supplies Not Removed
Penalty
Summary
The facility failed to ensure the removal of expired medications and supplies from the medication storage room, medication cart, and treatment cart. During an inspection, it was observed that several medications, including ibuprofen, vitamin C, probiotics, metoprolol, clonidine, loratadine, senna, aspirin, and vitamin D3, were past their use-by dates and still present in the medication cart. Additionally, expired Hepatitis B vaccines, Tubersol, Miralax powder, and other medications were found in the medication storage room. The staff, including a Certified Medication Aide (CMA) and a Licensed Practical Nurse (LPN), acknowledged that these items should have been removed. A specific incident involved a resident with type II diabetes mellitus who was administered Novolog insulin from a vial that had been opened beyond the recommended 30-day period. The LPN administering the medication was unaware of the proper protocol for insulin use after opening, mistakenly believing it could be used until the expiration date on the vial. The Director of Nursing (DON) later confirmed that the insulin should not have been administered and should have been disposed of after 30 days from the opening date.
Inaccurate MDS Assessment for Indwelling Catheter
Penalty
Summary
The facility failed to ensure accurate coding of a Minimum Data Set (MDS) assessment for a resident with an indwelling catheter. The resident, who had diagnoses including cerebral infarction and hypertensive heart disease with heart failure, was documented as cognitively intact and dependent on toileting assistance. An annual MDS assessment indicated the presence of an indwelling catheter. However, a physician's order had discontinued the catheter in February, prior to the quarterly MDS assessment, which incorrectly documented the resident as still having the catheter. The Director of Nursing (DON) confirmed that the catheter had been discontinued and acknowledged the error in the MDS assessment.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in meeting their care needs. Resident #9, diagnosed with bipolar disorder, major depressive disorder, and anxiety disorder, had a care plan that required the completion of the AIMS assessment quarterly and as needed. However, the last documented AIMS assessment was completed on January 27, 2024, indicating a failure to adhere to the quarterly schedule. The Director of Nursing (DON) confirmed that the assessment should have been completed quarterly. Resident #19, with diagnoses of displaced intertrochanteric fracture of the right femur and displaced fracture of the base of the neck of the left femur, had a care plan that included the use of a pressure sensor and a security mat. Upon inspection, neither the pressure sensor nor the security mat was in place, and the DON acknowledged that the care plan was not being followed. Additionally, Resident #11, diagnosed with bipolar disorder, major depressive disorder, and anxiety, had a care plan that lacked documentation of the bipolar disorder diagnosis. Similarly, Resident #13, with schizoaffective disorder and major depressive disorder, had a care plan that did not document the schizoaffective disorder diagnosis. The DON confirmed that these diagnoses should have been included in the care plans.
Non-Compliance with Physician's Orders for Resident Care
Penalty
Summary
The facility failed to adhere to a physician's orders for a resident who was admitted with diagnoses including displaced intertrochanteric fracture of the right femur, displaced fracture of the base of the neck of the left femur, and a history of falling. The physician's order, dated 5/23/24, required the use of elevating leg rests on the wheelchair due to edema and pressure offload boots when the resident was out of bed. However, observations on 05/29/24 and 05/30/24 revealed that the resident was in a wheelchair in the dining room and lobby without the legs elevated and without the pressure offload boots. Further inspection showed that the leg rests were on the resident's bedside table and the offload boots were under the bed, indicating non-compliance with the physician's orders. The Director of Nursing confirmed that the staff were not following the physician's orders.
Failure to Identify Psychotropic Medication Irregularities
Penalty
Summary
The facility failed to ensure that the consulting pharmacist identified irregularities and clinically significant risks associated with psychotropic medications for two residents. Resident #1, who was admitted with diagnoses including schizoaffective disorder and anxiety, had a physician order for lorazepam to be administered as needed for anxiety. Despite receiving lorazepam 29 times in May 2024, the monthly medication regimen reviews for March and April 2024 did not document any recommendations to limit the medication to 14 days unless a physician provided a rationale for extending its use. The Director of Nursing (DON) acknowledged that the consulting pharmacist missed this issue during the monthly reviews. Resident #15, admitted with diagnoses including dementia and major depressive disorder, had multiple psychotropic medications prescribed. The monthly medication regimen reviews from August 2023 to April 2024 did not document any recommendations for a gradual dose reduction (GDR) of these medications. Additionally, there was no documentation of attempts at GDR or a physician's rationale for the continued use of these medications. The DON confirmed that no GDR attempts had been made for this resident since admission, and the consulting pharmacist had not recommended any during the reviews.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Prague
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meeker Nursing Center | 11.7 mi | ★★★★★ | 9 | 0 |
| The Regency Skilled Nursing And Therapy | 15.6 mi | ★★★★★ | 0 | 0 |
| Shawnee Care Center | 16.8 mi | ★★★★★ | 1 | 0 |
| Shawnee Colonial Estates Nursing Home | 16.9 mi | ★★★★★ | 0 | 0 |
| Seminole Care And Rehabilitation Center | 17.2 mi | ★★★★★ | 0 | 0 |
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