Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Commons during CMS and state inspections, most recent first.
Food was found improperly stored in multiple kitchen areas, including dated and undated items, open containers, and foods past discard or use-by dates. During meal prep and service, several dietary staff had facial hair that was not fully covered, and a dietary aide used a surgical mask instead of a beard net. Staff also failed to perform hand hygiene while assisting residents with meals, after touching used utensils, adjusting clothing or a mask, and using a walkie talkie.
A resident with dry eye syndrome and moderate cognitive impairment had Refresh eye drops kept at the bedside and self-administered them, but the record lacked a self-administration assessment and the physician's order did not authorize self-administration or bedside storage. Surveyors observed the eye drops in reach of the resident, and staff and the physician confirmed that an assessment and order were expected before a resident could self-administer medication.
The facility failed to notify the physician when a resident’s Lasix was unavailable for administration. The resident had systolic CHF and an order for Lasix 20 mg daily, but the MAR showed repeated charting that the medication was not given because it was not available. Staff stated the nurse should notify the physician when a med is unavailable, yet the LPN was unaware the med was missing and the physician stated he had not been notified.
Failure to submit an updated PASRR after a resident developed new psychiatric diagnoses. A resident admitted with a Level I PASRR for dementia later had documented delusional disorder and depression, with the MDS showing active depression and a psychotic disorder and the MAR including Seroquel and Celexa. Staff gave inconsistent accounts of who was responsible for PASRR follow-up, and the facility had no PASRR policy.
Unsecured Catheter Tubing and Improper Drainage Bag Placement: A resident with an indwelling urinary catheter, severe cognitive impairment, and diagnoses of urinary retention and neurogenic bladder was observed with catheter tubing not secured and the urine collection bag lying directly on a fall mat at the bedside. Facility staff acknowledged the tubing should be secured and the bag should not be placed on the floor or fall mat, consistent with the facility’s catheter care guideline.
A dietary aide was observed entering and exiting a room on contact precautions without knowing what the precautions meant or what the posted sign indicated, and he stated he had not received infection control training. Facility interviews and policy review showed contact precautions required gown and gloves on room entry, but there was no documentation that the aide had required infection control, hand hygiene, or food handling training, and leadership stated no one recalled training him.
A dietary aide entered and exited a resident's contact isolation room without gown and gloves, despite posted contact precautions. The aide said he had not received infection control training and did not know what contact precautions were. The resident had intact cognition, an indwelling catheter, a UTI, and ESBL in the urine, and the IP, DON, and ADM stated staff entering contact precautions rooms were expected to use PPE.
Failure to Post Daily Nurse Staffing Data: The facility did not ensure nurse staffing data was posted in a prominent location accessible to residents, staff, and visitors. The survey team could not locate a staffing posting, and interviews showed the Scheduler did not post daily staffing, the Payroll Clerk sent staffing numbers to the Administrator but had not been instructed to post them publicly, and the Assistant Administrator, DON, and Administrator were unaware of a policy or requirement for daily staffing postings.
The facility did not submit required payroll-based staffing information to CMS for the third quarter of 2024. An interview with the administrator revealed a lack of awareness and process for ensuring data submission, affecting 95 residents.
Two residents with dementia and severe impairments were not provided with adequate assistance for personal hygiene, as observed by their uncombed hair and unshaven facial hair over several days. Despite the facility's expectations for residents to be presentable, there was inconsistency in the care provided, highlighting a deficiency in meeting the residents' ADL needs.
A resident with dementia had medications left unattended at their bedside without a physician's order for self-administration. Observations over several days showed medication cups with creams and powder on the counter in the resident's room. A CMA applied the powder without confirming an order, and an LPN later confirmed no order existed, highlighting a failure in medication storage protocols.
Food Storage, Facial Hair Coverage, and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure food was stored properly. During a kitchen tour, surveyors observed frozen chicken in a stainless-steel pan covered with clear plastic wrap and dated 02/17/2026, with areas of pink, light tan, and white discoloration on the top layer. In the walk-in freezer, 19 raw hamburger patties were stored in an open clear plastic bag inside a cardboard box dated 05/27/2026, and the Dietary Supervisor stated the chicken and hamburger patties were not properly stored and that the hamburger patties were not properly sealed. In the walk-in refrigerator, surveyors observed a partially opened container of yellow American cheese that was undated and exposed to air, three individual dishes of cake covered with plastic wrap that lacked dates, two containers of raw chicken dated 05/20/2026 surrounded by a thick liquid substance, white American cheese wrapped in plastic wrap and dated 12/21/2025, a bag of bacon bits with a use-by date of 05/25/2026, a piece of butter with a use-by date of 04/08/2026, turkey bologna with a use-by date of 04/08/2026, chopped beef brisket with a use-by date of 05/16/2026, cottage cheese with a use-by date of 05/30/2026, bacon bits in a resealable plastic bag dated 04/20/2026, potato salad with a use-by date of 05/29/2026 stored in a pan covered with plastic wrap, and individual cups of cream cheese with a use-by date of 08/22/2025. The Dietary Supervisor stated the cheese was not dated or properly sealed, the containers of chicken were past their discard date, and the other food items were not discarded in a timely manner. Surveyors also observed food items in the tray-line refrigerator and walk-in refrigerator that were not properly stored, including white cheese in an almost empty container covered with clear plastic wrap with pale, tan discoloration around the sides, an uncovered undated container of tartar sauce with dried residue on the interior sidewalls, an open undated bag of Parmesan cheese wrapped in clear plastic wrap, and a sheet pan approximately three-quarters full of cake covered with plastic wrap and undated. The Dietary Supervisor stated the food was not stored properly. The facility also failed to ensure staff utilized facial hair restraints when preparing, distributing, and serving food. During kitchen observations, multiple dietary staff members were seen preparing food and handling clean dishes and utensils with facial hair exposed, and their beards and mustaches were not completely covered with a hair restraint or protective covering. During a lunch meal observation, a dietary aide was observed wearing a surgical mask that did not fully cover facial hair. The dietary aide stated he used a surgical mask instead of a beard net and was unsure whether it was an appropriate replacement. The Dietary Supervisor, DON, and Administrator stated that facial hair, including upper lip hair, should be completely covered and that staff were expected to follow facility policy. The facility further failed to ensure hand hygiene was performed during meal service. During lunch in the main dining room, a dietary aide used a resident's unwrapped utensils to cut up the resident's meat, then returned to serving plates without performing hand hygiene. The same aide adjusted his pants, adjusted his surgical mask, and used a walkie talkie, each time returning to meal service without washing or sanitizing his hands. An LPN assisted one resident with cutting and feeding, then assisted another resident without sanitizing or washing her hands; another LPN picked up a resident's used cup, refilled it, returned it to the resident, and then continued helping another resident without hand hygiene. Staff interviews reflected that the aide and LPN understood hand hygiene should have been performed between residents and after touching items such as used dishware, clothing, a face covering, or a walkie talkie.
Failure to Assess and Order Self-Administration of Eye Drops
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, failed to obtain a physician's order for self-administration, and failed to obtain a physician's order to keep medication at the bedside for one resident. Facility policy required an interdisciplinary assessment of the resident's cognitive, physical, and visual ability before self-administration, along with a prescriber's order and documentation of bedside storage when applicable. The resident had a history of dry eye syndrome, a BIMS score of 11 indicating moderate cognitive impairment, and adequate vision with corrective lenses. The resident's care plan addressed dry eyes and directed staff to administer Refresh drops per physician orders, but it contained no documentation that the resident had been assessed to self-administer medication. The physician's order for Refresh ophthalmic solution directed staff to instill the drops in both eyes four times daily and did not include self-administration or bedside storage instructions. The MAR showed staff initials documenting administration of the eye drops, yet the resident's electronic record contained no evidence of a self-administration assessment. During observations, surveyors found two bottles of Refresh eye drops in a plastic cup on the resident's bedside table and later on an overbed table within reach of the resident. The resident stated the eye drops were self-administered independently, and on one occasion a CMA handed the resident the bottle and the resident placed drops in both eyes. Staff interviews confirmed that an assessment and physician order were expected before self-administration and bedside storage, while the physician stated the resident was not always alert and oriented and was not trustworthy to administer their own medication. The DON and Administrator stated medication found at bedside without an order or assessment should be removed, and the Administrator was not aware the eye drops had been in the room until surveyors found them.
Physician Not Notified When Resident’s Lasix Was Unavailable
Penalty
Summary
The facility failed to ensure the physician was notified when Resident #34’s Lasix was not available for administration. Resident #34 was admitted with a history of systolic congestive heart failure and had an order for Lasix 20 mg daily. The May 2026 MAR showed Lasix was documented with chart code 9 from 05/28/2026 through 05/31/2026, and a nurses progress note stated a voicemail was left with a hospice company for a refill of Lasix 20 mg. The June 2026 MAR again showed chart code 9 for Lasix from 06/01/2026 through 06/03/2026. During medication administration observation, the CMA stated Lasix was not available and had been ordered from a pharmacy, and stated the nurse was responsible for notifying the physician when a medication was not available. The LPN stated staff needed to contact the physician if a medication was not available and was not aware Lasix was unavailable for the resident. The physician stated he was not aware Lasix was not available and expected to be notified of any medication that was not available. The DON stated the charge nurse should call the pharmacy and notify the physician, and the Administrator deferred to the DON for physician notification.
Failure to Submit Updated PASRR After New Psychiatric Diagnosis
Penalty
Summary
The facility failed to submit a PASRR form to the state-designated authority after a resident developed a new psychiatric diagnosis. Resident #10 was admitted with a Level I PASRR that identified unspecified dementia as the primary diagnosis and indicated no evidence of serious mental illness or other mental disorder. The resident’s record later showed diagnoses of delusional disorder and unspecified depression, and the quarterly MDS documented active depression and a psychotic disorder with a BIMS score of 5, indicating severe cognitive impairment. The care plan also reflected treatment for depression and delusional disorder, and the medication record included Seroquel for delusional disorder and Celexa for depression. During interviews, facility staff gave differing accounts of who was responsible for PASRR follow-up. The Assistant Administrator stated the facility had no PASRR policy. The ADON said she would call the state agency if a new psychiatric diagnosis was added but was unsure of the facility policy or federal requirements. Another ADON stated a new diagnosis required a new PASRR, but she was unsure who was currently responsible. The DON stated the MDS nurse or Case Manager was responsible for submitting a new PASRR and expected it to be submitted as soon as the new diagnosis was added. The PIDA stated that a resident admitted with a Level I PASRR and a significant change such as a new diagnosis may need a new Level I PASRR sent to the state-designated authority. The Administrator stated PASRR review and submission of an updated Level I PASRR was a collaborative team effort.
Unsecured Catheter Tubing and Improper Drainage Bag Placement
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling urinary catheter when the catheter tubing was not secured and the urine collection bag was placed directly on a fall mat on the floor at the resident’s bedside. Resident #60 was admitted with diagnoses of retention of urine and neuromuscular dysfunction of the bladder, had severe cognitive impairment with a BIMS score of 3, and had an indwelling catheter during the assessment look-back period. The resident’s care plan identified the need for an indwelling urinary catheter due to a neurogenic bladder and included interventions to check the tubing each shift and monitor the catheter system for compromise. The facility’s catheter care guideline stated that catheter tubing should be positioned properly to prevent pulling and that the drainage bag should be kept below bladder level and secured properly. During observation, the resident’s catheter tubing was observed unsecured, and the drainage bag was lying on the fall mat. In interview, the ADON/Infection Preventionist stated the tubing should be secured and the bag should not be directly on the fall mat because that could allow bacteria into the system. The DON stated the tubing should be secured to the resident’s leg and that the bag should not be on the floor or fall mat, and the Administrator deferred to the DON on these issues.
Dietary Staff Not Trained on Contact Isolation PPE
Penalty
Summary
The facility failed to ensure dietary staff were trained on the personal protective equipment required for contact isolation. During an observation and concurrent interview, a Dietary Aide was seen entering and exiting a resident room with contact precautions signage posted outside the room. The aide stated he had worked at the facility for almost three years, did not know what contact precautions were, could not identify what the posted sign meant, and said he had not received any infection control training. Facility interviews and policy review showed the Infection Control and Isolation Guideline required gown and gloves upon room entry for contact precautions. The Dietary Supervisor stated dietary aides reported to her and that their infection control training consisted of computer training and a food handler card. The Regional Nurse stated there was no documentation that the Dietary Aide had a food handler card, infection control training, or hand hygiene training, and said he had been working without the required dietary training. The ADON/infection preventionist stated she trained the Dietary Supervisor rather than meeting directly with dietary aides, and the Administrator stated no one on current staff recalled training the aide on infection control, handwashing, or food handling.
Failure to Use PPE in Contact Isolation Room
Penalty
Summary
The facility failed to ensure dietary staff used PPE when entering a resident's room under contact isolation precautions. Dietary Aide #15 entered and exited Resident #45's room without donning a gown and gloves, despite signage outside the room indicating contact precautions. During observation, the aide was seen going into and out of the room without PPE and stated he had worked at the facility for almost three years, had not received infection control training, did not know what contact precautions were, and could not identify the posted signage. Resident #45 had intact cognition with a BIMS score of 15 and had an indwelling catheter, a multidrug resistant organism, and a UTI. The resident's care plan identified infection risk related to the catheter and a history of ESBL resistance, and the resident was on contact precautions for ESBL in the urine. The Infection Preventionist stated staff should don a gown and gloves before entering contact isolation rooms and that dietary staff should not go into such rooms, while the DON and Administrator stated staff entering contact precautions situations were expected to be trained on how to don protective barriers.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure nurse staffing data was posted in a prominent place accessible to residents, staff, and visitors on 1 of 5 survey days. During an observation on 06/02/2026, the survey team was unable to locate a nurse staffing data posting. During interviews, the Scheduler stated she created the nurse schedule in the electronic system but did not run or post a daily staffing report in the facility, and the Payroll Clerk stated she ran daily staffing numbers and sent them to the Administrator but had never been instructed about a requirement for public daily staff postings. The Assistant Administrator stated the facility did not have a policy related to posting nurse staffing, the DON stated she was not aware of any daily staff posting requirements and did not know whether anyone had been tasked with posting the data, and the Administrator stated he was not previously aware of a regulation requiring daily staff posting and was unsure whether anyone posted daily staffing hours.
Failure to Submit Payroll-Based Staffing Data
Penalty
Summary
The facility failed to submit payroll-based staffing information to CMS for the third quarter of 2024. This deficiency was identified through record review and interview. The PBJ Staffing Data Report for FY Quarter 3 2024 showed no data submission for the specified period. During an interview on October 31, 2024, the administrator admitted to not being aware of anyone completing the submission process and acknowledged uncertainty about whether the process was being followed to ensure the data was accepted. At the time of the deficiency, the facility housed 95 residents.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents who were dependent on staff for personal hygiene. Resident #21, diagnosed with dementia, was observed on multiple occasions with uncombed hair and unshaven facial hair, indicating a lack of personal hygiene care. Despite being severely impaired in daily decision-making and dependent on staff for personal hygiene, the resident's grooming needs were not met over several days. Similarly, Resident #64, also diagnosed with dementia and having upper extremity impairment, was observed with uncombed hair and unshaven facial hair on multiple occasions. Although a CNA was observed shaving the resident at one point, the care was not consistent, as evidenced by the resident's appearance on other days. The facility's administration acknowledged the expectation for residents to be presentable, with hair brushed and shaving done regularly, but there was a lack of clarity on how staff were informed of the specific care needs for each resident.
Medications Left Unattended at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications were not left at a resident's bedside, specifically for a resident diagnosed with dementia. The resident had physician orders for topical treatments, including Vicks Vapor rub, nystatin powder, and Aquaphor, but there were no orders for self-administration of these medications. Despite this, medication cups containing white cream and powder were observed on the counter near the sink in the resident's room over several days, indicating that the medications were left unattended and accessible to the resident. During observations, the resident was seen in their wheelchair and was able to move around the room, suggesting they could potentially access the medications. A CMA was observed applying the powder to the resident without confirming if there was an order for bedside medication. When questioned, the CMA admitted they were unsure if the resident had an order to keep medications at the bedside. An LPN later confirmed that there was no such order, indicating a lapse in following proper medication storage protocols.
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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 Enid
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garland Road Nursing & Rehab Center | 1.4 mi | ★★★★★ | 3 | 2 |
| Greenbrier Village Health And Rehabilitation | 3.5 mi | ★★★★★ | 2 | 0 |
| Baptist Village Of Enid | 3.9 mi | ★★★★★ | 2 | 0 |
| The Living Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Enid Senior Care | 5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.