Garland Road Nursing & Rehab Center
1404 North Garland Road, Enid, OK 73703 · For profit - Corporation · 118 certified beds · (580) 234-2526 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.6% | 13.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.0% | 3.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.3% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.0% | 3.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.9% | 4.7% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.7% | 13.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.0% | 25.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.3% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.1% | 17.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.0% | 17.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 74.6% | 74.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 17.7% | 27.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.7% | 16.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.57 | 2.31 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.97 | 2.96 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.7%CMS range 44.4–63.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 7.1–14.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 73.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 62.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 5.5–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 118 beds and averages 80.6 residents a day — about 68% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.49 on weekdays — 8% thinner on weekends. RN hours go from 0.36 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · K2026-01-08 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 12/23/25 at 12:11 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to ensure a comprehensive care plan was developed for Resident #8 to prevent an elopement.Resident #8 was cognitively impaired with a BIMS score of 2. Resident #8 had two elopement assessments which identified Resident #8 as a moderate risk for elopement.Resident #8's care plan did not show elopement as a risk and did not contain any interventions.On 12/09/25, Resident #8 eloped from the facility. The resident was located nearby at a church with scratches. On 12/23/25 at 12:31 p.m., the administrator, DON, ADON, corporate nurse #1, dietary manager, and RDO were notified of the immediate jeopardy (IJ) situation and provided the IJ template.On 12/23/25 at 4:38 p.m., an acceptable plan of removal was accepted by the Oklahoma State Department of Health. The plan of removal showed,a. Residents with an elopement score greater than 11 should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Kcited before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 12/23/25 at 12:11 p.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy (IJ) situation related to the facility's failure to ensure Resident #7 was not dropped from a mechanical lift during a transfer.Resident #7's quarterly assessment, dated 07/23/25, showed their cognition was intact with a BIMS score of 15. The assessment showed Resident #7 was dependent for all transfers.A facility incident report, dated 12/16/25, showed Resident #7 had a fall from a mechanical lift on 12/16/25 when a sling broke resulting in a fracture to the right clavicle and the left tibia.On 12/23/25 at 12:31 p.m., the administrator, DON, ADON, corporate nurse #1, dietary manager, and RDO were notified of the immediate jeopardy (IJ) situation and provided the IJ template.On 12/23/25 at 4:38 p.m., an acceptable plan of removal was accepted by the Oklahoma State Department of Health. The plan of removal showed,a. Resident #7 was sent to the hospital on [DATE] and returned to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-21 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident's care plan was updated with interventions to prevent wandering into other residents' room for 1(#4) of 3 sampled residents reviewed for care plans interventions. The administrator identified 102 residents resided in the facility.Findings: On 09/23/25 at 3:30 p.m., Resident #5 was observed seated on their walker at the nurses' station with a fast-food bag in their hands. Resident #5's care plan, dated 6/20/25, showed Resident #5 had a focus for wandering into other residents' rooms. The interventions were dated 06/20/25 which included redirecting the resident and analyzing the circumstances, times, and places to deescalate the resident's behavior.Resident #5's nursing note, dated 07/08/25, read in part, .resident found in [gender withheld] residents' bed. Resident asleep near private area. Both residents fully clothed. Resident removed from [gender withheld] residents' bed and took back to [their] own room. Resident #5's nursing note, dated 07/10/25, read in part, .Resident found trying to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-22 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to notify the physician when a resident:a. missed their prescribed antibiotic dose; and b. had an abnormal heart rate for 1 (#6) of 3 sampled residents reviewed for medication administration.The administrator identified 97 residents resided in the facility.Findings:A MEDICATION-GUIDELINES ON CLINICAL PRACTICE policy, revised 01/12/20, read in part, Staff will provide medications in accordance with standard practice guidelines.Resident #6's quarterly resident assessment, dated 08/09/25, showed the resident had diagnoses which included congestive heart failure and unspecified atrial fibrillation.A physician's order, dated 07/24/25, showed metoprolol succinate (an antihypertensive) 50 mg tablet, extended release for essential primary hypertension. Give one tablet by mouth three times a day. Take one 50mg tablet if systolic blood pressure is less than 110.A physician's order, dated 08/03/25, read in part, ciprofloxacin hydrochloride (an antibiotic) 500 mg tablet for urinary tract infection. Start 08/04/25 at 08:00 [8:00 a.m.].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide showers as scheduled for 3 (#2, 5, and #6) of 3 sampled residents reviewed for showers.The DON identified 97 residents required assistance with bathing. Findings:A BATHING (NOT PARTIAL OR COMPLETE BED BATH) policy, revised 02/12/20, read in part, Staff will provide bathing services for residents within standard practice guidelines.1. Resident #2's quarterly resident assessment, dated 07/31/25, showed the resident had diagnoses which included unspecified hemiplegia affecting left nondominant side. The assessment showed the resident's cognition was intact with a BIMS of 15. The assessment showed the resident required setup or clean-up assistance with showers.There was no documentation the resident had a shower on 06/03/25, 06/05/25, 06/07/25, 06/24/25, and 06/26/25.The June 2025 shower sheets showed the resident refused a shower on 06/12/25, 06/14/25, 06/19/25, and 06/25/25.Resident #2 had three out of 12 showers for the month of June 2025.There was no documentation the resident had a shower on 07/01/25, 07/03/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-22 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to administer medication as ordered for 2 (#5 and #6) of 3 sampled residents reviewed for medication administration.The administrator identified 97 residents resided in the facility. Findings:A MEDICATION-GUIDELINES ON CLINICAL PRACTICE policy, revised 01/12/20, read in part, Staff will provide medications in accordance with standard practice guidelines.1. A physician's order for Resident #5, dated 06/18/25, showed insulin glargine 100units/1mL, give 30 units subcutaneous at bedtime for type 2 diabetes mellitus without complications.A June 2025 Medication Record showed M on 06/20/25 for 9:00 p.m. dose. Resident #5's discharge assessment return not anticipated, dated 07/12/25, showed the resident had diagnoses which included type 2 diabetes mellitus without complications.On 08/22/25 at 11:32 a.m., LPN #2 stated they were not sure what the M meant on the medication record. They stated the medication record did not show the insulin was administered on 06/20/25.On 08/22/25 at 11:33 a.m., LPN #2 stated if a resident refused their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-22 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the amount of insulin administered was documented on a resident who received sliding scale insulin for 1 (#5) of 3 sampled residents reviewed for medication administration.The DON identified 28 residents received insulin resided in the facility. Findings:A MEDICATION-GUIDELINES ON CLINICAL PRACTICE policy, revised 01/12/20, read in part, Staff will provide medications in accordance with standard practice guidelines.A physician's order for Resident #5, dated 06/21/25, showed Humalog kwikpen 200 units/1mL solution. Give one dose subcutaneous for blood sugar 70-100= 0 units, 100-150= 4 units, 151-200= 6 units, 201-250= 8 units, 251-300= 10 units, 301-350= 12 units, 351-400= 14 units, 401-500= 16units, over 500, give 5 additional fast acting units before meals and bedtime for type 2 diabetes mellitus with ketoacidosis without coma.A Medication Record reviewed from 06/21/25 through 06/30/25 did not show how many units of the sliding scale insulin was administered for all blood sugars above 100.A physician's order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-22 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a resident had a physician's order and a self-administration of medication assessment for 1 (#6) of 3 sampled residents reviewed for medication administration.The administrator identified 97 residents resided in the facility. Findings: On 08/20/25 at 12:49 p.m., fluticasone propionate (a corticosteroid) nasal spray was observed on Resident #6's bedside table.A MEDICATION PROGRAM policy, revised 12/01/23, read in part, Residents who self-administration their medication and keep them locked in their room must be counseled at least monthly by community staff to ascertain if the residents continue to be capable of self-administering their medications/treatments and if security of the medications can continue to be maintained. The community must keep a written record of such counseling.A physician's order, dated 03/11/25, showed fluticasone propionate nasal spray 50 micrograms, give one spray twice a day for unspecified cough.Resident #6's quarterly resident assessment, dated 08/09/25, showed the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident with low blood sugar received appropriate care for 1 (#5) of 3 sampled residents reviewed for medication administration.The DON identified 28 residents received insulin resided in the facility. Findings:A HYPOGLYCEMIA TREATMENT policy, revised 02/12/20, read in part, Guidelines for Mild Hypoglycemia: Treat, even if biochemical hypoglycemia is not present with a. glucose-15 40% oral gel (Dextrose) gm gel, b. Glucose 15 gm tablets.Repeat blood glucose level in fifteen (15) minutes.A physician's order, dated 06/21/25, showed Humalog kwikpen 200 units/1mL solution. Give one dose subcutaneous for blood sugar 70-100= 0 units, 100-150= 4 units, 151-200= 6 units, 201-250= 8 units, 251-300= 10 units, 301-350= 12 units, 351-400= 14 units, 401-500= 16units, over 500, give 5 additional fast acting units before meals and bedtime for type 2 diabetes mellitus with ketoacidosis without coma.A Medication Record for Humalog sliding scale on 07/06/25 for 7:00 a.m. dose, showed insulin was held due to vital signs parameters.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-06 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure MDS assessments were accurate for 2 (#28 and #81) of 24 residents sampled for MDS assessments. The administrator identified 91 residents resided in the facility. Findings: A policy titled Resident Assessment, dated 09/13/17, read in part, It is the standard of Care to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual.The assessment process included direct observation, the medical record, as well as communication with the resident and direct care staff across all shifts. 1. Resident #28's admission record, dated 09/14/24, showed they were admitted with diagnoses which included end stage renal disease and displaced fracture of the lower right leg. Resident #28's physician orders, dated 09/14/24, read in part, Dialysis Monday, Wednesday and Friday on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-06 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure: a. a physician's order was obtained for a medication kept at beside to treat an abrasion for 1 (#55); b. a physician's order was in place for a treatment that was provided for 1 (#55); c. an abrasion was assessed routinely for 1 (#55) of 2 sampled residents reviewed for skin conditions; and d. communication was maintained with hospice for 1 (#68) of 1 sampled resident reviewed for hospice services. The administrator identified 91 residents resided in the facility. The ADON identified 10 residents received hospice services. Findings: 1. On 04/28/25 at 2:10 p.m., LPN #1 was observed to go into Resident #55's room, pick up a tube of mupirocin (topical antibiotic) ointment from the resident's bedside table, and apply it to Resident #55's head. On 05/06/25 at 12:55 p.m., the back of Resident #55's head was observed. A ribbon of cotton was observed on the left side of Resident #55's head. A medication box of triple antibiotic ointment was observed on the dresser next to the resident. The directions on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure: a. staff donned gloves when applying an ointment to a resident for 1 (#55) of 2 sampled residents reviewed for wound care; b. staff changed gloves while performing peri-care to a resident for 1 (#23) of 1 sampled resident observed for peri-care; c. trends in infections were identified through monthly review of tracking for 3 of 3 sampled months reviewed; and d. respiratory equipment was bagged and labeled for 1 (#24) of 2 sampled residents reviewed for respiratory care. The administrator identified 91 residents resided in the facility. The ADON identified 17 residents received oxygen services and 28 residents had nebulizers. Findings: 1. On 04/28/25 at 2:06 p.m., LPN #1 was observed to apply mupirocin (topical antibiotic) ointment to the back of Resident #55's head with out wearing gloves. A policy titled Non-Pressure Wound, dated July 2018, showed to follow standard precautions and infection control methods. A Quarterly Assessment, dated 03/13/25, showed Resident #55's BIMS score was 15, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · Dcited before2025-05-06 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to assess a resident for self administration of medication and obtain a physician order for a resident to self administer medication for 1 (#55) of 1 sampled resident reviewed for self administration of medication. The administrator identified 91 residents resided in the facility. Findings: On 04/28/25 at 2:10 p.m., LPN #1 was observed to go into Resident #55's room, pick up a tube of mupirocin (topical antibiotic) ointment from the resident's bedside table, and apply it to Resident #55's head. On 05/06/25 at 12:55 p.m., Resident #55 was observed sitting in their recliner in their room. A medication box of triple antibiotic ointment was observed on the dresser next to the resident. May keep at bedside was hand written on the box. A policy titled Bedside Medication Storage, dated 01/2024, read in part, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on obsevation, record review, and interview, the facility failed to ensure a resident's room was free from odors for 1 (room [ROOM NUMBER]) of 24 rooms observed for odors. The administrator identified 91 residents resided in the facility. Findings: On 04/30/25 at 9:59 a.m., room # 217 was observed to have a strong odor of urine. A policy titled Resident Room Cleaning, dated 11/2021, read in part, To provide a clean, attractive, and safe environment for residents, visitors, and staff. On 04/30/25 at 10:04 a.m., CNA #5 was asked what they smelled in room [ROOM NUMBER]. They stated they smelled urine. CNA #5 stated the urine smell came from the floor and the bathroom because the resident was incontinent. They were asked if the smell facilitated a homelike environment. CNA #5 stated, No, it's not a homelike environment. On 04/30/25 at 10:20 a.m., LPN #2 was asked what the facility's policy and rule was about having a homelike environment. They stated the facility should be kept clean with no odors and made to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure oxygen tanks were stored in a safe place for 1 (#68) of 2 residents sampled for safe oxygen tank storage. The ADON identified 17 residents received oxygen therapy. Findings: On 04/30/25 at 10:06 a.m., an oxygen concentrator and two oxygen tanks were observed in Resident #68's room. One oxygen tank was secured to a cart with a strap. One tank was observed in the corner of the room loose and leaned up against the wall. On 04/30/25 at 10:20 a.m., oxygen tanks were observed in Resident #68's room. One oxygen tank was secured to a cart with a strap. One tank was observed in the corner of the room loose and leaned up against the wall. An undated policy titled Oxygen Storage Handling, read in part, All oxygen cylinders are to be stored in a fire safety closet and locked .Cylinders shall be stored away from doors and secured to its location by a non combustible strap or chain to avoid tipping. Resident #68's admission record, dated 10/30/24, showed they were admitted with diagnoses which included cirrhosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-06 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure dental services were provided for 1 (#81) of 24 residents sampled for dental services. The ADON identified 73 resident had a payer source of Medicaid and eight residents received dental services. Findings: An undated policy titled 'Availability of Services, read in part, Oral healthcare and dental services will be provided to each resident.Social Services will be responsible for making necessary dental appointments. An undated policy titled Routine Dental Care, read in part, Our facility's routine dental care includes, but is not limited to: .Consultation with the resident, staff, and the dental consultant. Resident #81's admission record, dated 01/28/25, showed the resident was admitted with diagnoses which included alcoholic cirrhosis of the liver, chronic hepatic failure, and liver cell carcinoma. The record showed they had a payer source of Medicaid. Resident #81's admission assessment, dated 01/31/25, showed moderate cognitive impairment with a BIMS score of 12, required set up or clean up assist…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to: 1. allow the resident council group to meet without staff present, and 2. act promptly upon grievance about unsanitary practices regarding the ice chests presented to staff for three of three resident council meetings for which minutes were reviewed. The Administrator identified 83 residents resided in the facility. Findings: 1. Regulation 310:675-7-7 Resident's advisory council, read in parts, .(c) No employee or affiliate of the facility shall be a member of the council . On 12/19/23 at 2:11 p.m., this surveyor attended a scheduled resident council meeting at the invite of the council president. There were ten residents and one staff member in attendance. Resident #58 reported the staff member, Activity Asst., was the secretary of the resident council and had been appointed by the Administrator. Resident #58 stated they had been told by the Administrator the secretary of the resident council had to be a staff member. On 12/21/23 at 9:00 a.m., the Administrator was asked if the residents were told they had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the DON did not serve as a charge nurse when the average daily occupancy was more than 60 residents. The Administrator identified 83 residents resided in the facility. Findings: A Census Daily Detail report, dated 12/01/23 to 12/21/23, documented the daily census ranged from 85 to 91 residents. A Schedule Sheet, dated December 2023, documented the DON was assigned as a charge nurse for the following days: 12/02/23, 12/03/23, 12/04/23, 12/09/23, and 12/18/23. On 12/18/23 at 2:26 p.m., the DON was observed sitting at the nurses' station on the phone. The receptionist stated the DON was working the floor today. On 12/20/23 at 11:10 a.m., the Administrator stated the DON had been working the floor. The Administrator stated, I have no nurses. On 12/21/23 at 2:09 p.m., the DON was asked how often she worked the floor. She stated whenever she needed to fill in. She was asked if the days her name was on the schedule, were the days she worked the floor. She stated, Yes.
- Potential for harm · Ecited before2023-12-22 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure medications were administered per physician's orders for two (#83 and #89) of seven sampled residents reviewed for medications. The Administrator identified 83 residents resided in the facility. Findings: A Medication Administration policy, dated 09/2018, read in part, .Medications are administered as prescribed .within 60 minutes of scheduled time, except before .meal orders, which are administered based on mealtimes . 1. Resident #83 had diagnoses which included hypomagnesium. Resident #83's Consolidated Order summary, dated 07/28/23, documented the resident was to receive two tablets of magnesium twice a day. On 12/20/23 at 7:11 a.m., CMA #2 was observed to prepare Resident #83's medications. They were observed to place one table of magnesium in the medication cup and administered it to the resident. On 12/20/23 at 8:29 a.m., CMA #2 was asked how they ensured medications were administered as ordered. They stated they checked the medication card and compared it to the physician's order. CMA #2 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure medication regimen reviews were responded to by the physician in a timely manner for two (#30 and #72) of five sample residents reviewed for unnecessary medications. The Administrator identified 83 residents resided in the facility. Findings: A Medication Monitoring policy, dated 11/2017, read in part, .The consultant pharmacist and the nursing care center follows up on the recommendations .within 30 calendar days . 1. Resident #30's medication regimen review, dated 11/17/23, read in part, .This resident has been taking omeprazole 40 mg [every day] since 7/25/21 without a dose reduction. Please consider a trial dose reduction to 20 mg daily . There was no response from the physician. 2. Resident #72's medication regimen review, dated 09/06/23, read in part, .This resident has been taking the anxiolytic Risperdal Consta .every 14 days since March 2023. Please evaluate the current dose and consider a dose reduction . There was no response from the physician. On 12/21/23 at 2:09 p.m., the DON was asked what was the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-22 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to implement their infection control program to prevent potential spreading of COVID-19 infection for all staff and residents. The facility failed to: a. isolate COVID-19 positive residents for 10 days, and b. conduct contract tracing on staff who provided care to COVID-19 positive residents for two (#30 and #65) of three sample residents reviewed for COVID-19 precautions. The Administrator identified 83 residents who resided at the facility. Findings: A COVID-19 Outbreak Management Plan-Oklahoma SNF policy, dated 05/12/23, read in part, .for residents who are positive they are to .isolate for 10 full days (they do not have the option to test out at 7 days), and contacts will be tested on days 1, 3, and 7 . A Physician's Order, dated 12/11/23, documented Resident #30 was on isolation for 11 days for a diagnosis of COVID-19. On 12/18/23 at 12:03 p.m., Resident #30 was observed in the main dining room without a mask. On 12/18/23 at 12:37 p.m., Resident #30 was observed to be taken back to their room from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-22 · tag F0680 — isolatedEnsure the activities program is directed by a qualified professional.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, and interview, the facility failed to have a qualified activities director. This had the potential to affect 83 residents that resided in the facility. The Administrator identified 83 residents resided in the facility. Findings: A Job Description activities director, undated, read in part .2 years of experience in a social or recreational program .completed a state-approved training course . On 12/21/23 at 11:33 a.m., the Activities Director was asked if they had taken or enrolled in a activity director certification course. They stated, No. On 12/21/23 at 11:37 a.m., the Administrator was asked if the activity director has finished or enrolled in a activity director certification course. They stated No, they are not enrolled yet. They were asked if any of the activity staff were certified in activities. They stated, No.
- Potential for harm · F2023-01-06 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, the facility failed to: a. offer snacks to all residents and b. provide meals within the scheduled meal times for eight (#1, 18, 19, 31, 65, 70, 78, and #82) of 14 sampled residents reviewed for dietary services. The DON identified 98 residents received meals from the dining room. Findings: A Snacks and Supplements policy, dated 08/01/18, read in parts, .The Nutrition Services employee will prepare snacks and supplements in accordance with physician's order or recommended snack menu .Physician-ordered supplements (or snacks) and all-purpose snacks are prepared and available to residents three times daily .All physician-ordered supplements (or snacks) will be labeled with residents name, room number, diet, date, and time (am, pm, hs) for delivery .HS snacks will include a variety of foods to ensure each resident has an opportunity for snacks . A Join us in the Dining in Room! document, undated, read in part, .Breakfast 7:30 a.m. - 8:30 a.m .Lunch 11:45 a.m. - 1:00 p.m .Dinner 5:00 p.m. - 6:30 p.m .Room Service Dining is also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-01-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview the facility failed to ensure: a. potentially hazardous food products were stored at proper temperatures, b. bags and boxes of food were not stored on the floor, c. food service equipment was kept clean and d. monitoring was completed for the dishwasher machine temperature and sanitizer. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 98 residents resided in the facility. The DON identified 98 residents received nutrition from the kitchen. Findings: A Food Storage policy, effective 08/01/18 read in parts, .Refrigerators: Temperatures for refrigerators are at or below 40 degrees Fahrenheit .Air tight container or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened .Temperatures are checked at least twice daily. (See Refrigerator/Freezer Temperature logs) .Ready to eat foods are stored above raw meats, poultry, seafood, and eggs .All foods are stored off the floor . A Dish Machine Temperature Log Low Temp Machine policy, effective…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, observation, and interview, the facility failed to ensure two medication/treatment carts were secured for two of two medication/treatment carts observed unlocked and unattended. The DON identified the facility had three treatment carts and five medication carts. Findings: A Medication Storage policy, dated 11/2017, read in part, .Medication rooms, cabinets and medication supplies should remain locked at all times when not in use or attended . On 01/04/23 at 4:08 p.m., two treatment carts located on hall 500 were observed to be unlocked and unattended. On 01/04/23 at 4:09 p.m., LPN #2 was observed to come out of a resident's room and locked one of the treatment carts. On 01/04/23 at 4:10 p.m., LPN #1 was observed to lock the other treatment cart. LPN #1 was asked what the policy was for securing treatment carts. They stated to keep them locked. LPN #1 was asked what was kept on the treatment carts. They stated insulins, narcotics, and treatments.
- Potential for harm · E2023-01-06 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, the facility failed to ensure meals were palatable and at an appetizing temperature for 11 of 14 (#15, 18, 31, #35, 51, 52, 65, 70, 78, 82, and #344) sampled residents for dietary services. The DON identified 98 residents received services from the kitchen. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 98 residents resided in the facility. Findings: A General Food Preparation and Handling policy, dated 01/08/18, read in parts, .Food items are prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of harmful organism and substances . Resident Council meeting minutes, dated 10/18/22, read in part, .The cooking is lousy. Some foods are coming to residents raw and cold. The food can also be tough, and the hot rolls are hard . Resident Council meeting minutes, dated 11/15/22, read in part, .the Brussels sprouts were burnt, and the brownies were like chocolate rocks. Resident states that they cannot cook . On 01/04/23 at 9:56 a.m., Resident #70 was asked how the food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-06 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure residents received thickened liquids per physician's orders for two (#16 and #68) of two sampled residents reviewed for therapeutic diets. The RD identified nine residents had physician's orders for nectar thick liquids. Findings: A Thickened Liquids policy, dated 08/01/18, read in part, .All residents requiring thickened liquids will be served in a consistency to minimize the risk of choking and aspiration .Pre-thickened liquids will be served at meals . 1. Resident #16 had diagnoses which included pneumonia. A Physician's Order, dated 12/27/22, documented Resident #16 was to receive nectar thick liquids. On 01/06/23 at 9:02 a.m., Resident #16's breakfast meal tray was observed on the hall tray cart with a glass of milk and orange juice. Resident #16's meal ticket on the tray documented nectar thick liquids. On 01/06/23 at 9:04 a.m., the ADON was asked if Resident #16's milk and orange juice were thickened. The ADON stated no. The ADON was asked who was responsible to thicken the liquids. The ADON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure staff utilized appropriate PPE and washed their hands between gloves changes while providing wound care to a COVID-19 positive resident for one (#16) of one sampled resident reviewed for wound care. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 98 residents resided in the facility. The Administrator identified 11 COVID-19 positive residents in the facility. Findings: An Infection Control policy, revised 11/2022, read in part, .If caring for a person with COVID-19 .Upon entering room staff will wear a .N95 .face shield or goggles, gown and gloves . Resident #16 had diagnoses which included COVID-19 and wounds to their sacrum and left heel. A Physician's Order's, dated 12/24/22, documented the following: a. cleanse sacral wound with wound cleanser, place wet gauze soaked in dakins solution to wound, and cover with an island dressing twice daily, and b. cleanse the left heel wound with wound cleanser, pat dry, place medi honey to the area, cover with calcium alginate,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure a resident did not self administer medications without a physician's order for one (#43) of one sampled resident observed to self administer medications. The DON identified no residents had orders to self administer medications. Findings: Resident #43 had diagnoses which included pain. A Physician's Order, dated 06/16/21, documented to administer ibuprofen 800 mg three times daily as needed for pain. On 01/04/23 at 4:20 p.m., Resident #43 was heard hollering out, I'm waiting for ice water to take my aspirin. On 01/04/22 at 4:21 p.m., Resident #43 was observed in their bed with a medication cup sitting on their bedside table. There was one tablet observed in the medication cup. On 01/04/23 at 4:21 p.m., CNA #1 entered the room and Resident #43 told the CNA they needed ice water. On 01/04/23 at 4:22 p.m., CNA #1 was observed to return to the room with ice water, sat it on the resident's bedside table, and left the room. Resident #43 was observed to self administer the medication. On 01/04/23 at 4:25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to investigate a report of misappropriation of resident's property for one (#344) of one sampled resident reviewed for misappropriation. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 98 residents resided in the facility. Findings: A Resident Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 06/23/17, read in part, .The facility must prohibit .misappropriation of resident property .misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator .Upon learning of a suspected incident of resident .misappropriation of resident property, the Charge nurse or other Department Manager or Supervisor must immediately notify the Abuse Coordinator or the DON . Resident #344 had diagnoses which included depression. A Resident Assessment, dated 10/18/22, documented Resident #344's cognition was intact. On 01/04/23 at 1:42 p.m., Resident #344 stated when they were away from the facility on approximately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-06 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a baseline care plan accurately reflected a foley catheter for one (#16) of one sampled resident reviewed for catheters. The DON identified five residents with foley catheters. Findings: Resident #16 had diagnoses which included bacterial pneumonia, seizures, and unspecified skin changes. A Baseline Care Plan, dated 01/02/23, did not document Resident #16 had a foley catheter. On 01/04/23 at 10:45 a.m., Resident #16 was observed in bed. A catheter drainage bag was observed to be hanging on the right side of Resident #16's bed frame. On 01/06/23 at 3:28 p.m., the DON was asked if the foley catheter was on Resident #16's baseline care plan. She stated no.
- Potential for harm · D2023-01-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure physician's orders were obtained for a foley catheter and catheter care for one (#16) of one sampled resident reviewed for catheters. The DON identified five residents with foley catheters. Findings: Resident #16 had diagnoses which included bacterial pneumonia, seizures, and unspecified skin changes. A Care and Removal of an Indwelling Catheter policy, dated 01/12/20, read in part, .Staff will provide care .in accordance with standard practice guidelines .Perform catheter care . On 01/04/23 at 10:45 a.m., Resident #16 was observed in bed. A catheter drainage bag was observed to be secured to the right side of the bed frame. On 01/05/23 at 3:40 p.m., Resident #16 was observed in bed. A catheter drainage bag was observed to be secured to the right side of the bed frame. On 01/06/23 at 3:28 p.m., the DON was asked what the policy was when a resident had a foley catheter. She stated staff would obtain daily outputs, check the catheter daily, and change it monthly. The DON was asked where that information…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a medication had been administered as ordered for one (#66) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 01/04/23, documented 98 residents resided in the facility. Findings: A Medication Administration policy, dated 05/2016, read in part, .Medications are administered as prescribed . Resident #66 had diagnoses which included pseudobulbar affect. A Physician's Order, dated 12/16/22, documented to administer Nuedexta 20mg - 10mg capsule daily for pseudobulbar affect. The December 2022 MAR for Resident #66 documented the following for Nuedexta: a. 12/16, 12/23, 12/28, 12/29, and 12/30/22 due to special requirement parameters, b. 12/19 and 12/22/22 Refused, c. 12/17, 12/18, 12/20, 12/21, 12/24, 12/25, 12/26, and 12/27/22 were initialed as administered, and d. 12/31/22 On hold. The January 2022 MAR for Resident #66 documented Nuedexta had been held on 01/01 and 01/06/23 and that it was On hold 01/02/23 through 01/05/23. Pharmacy Manifests, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to STONEGATE SENIOR LIVING — 24 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 1 of 5 | 2.3 | -1.3 vs chain |
| Staffing | 4 of 5 | 2.3 | +1.7 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 23 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PF GARLAND SNF OPS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 11/01/2020 |
| SANCTUARY LTC, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/23/2021 |
| PRESERVATION FREEHOLD COMPANY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 09/23/2021 |
| UMB BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 09/23/2021 |
| STONEGATE SENIOR LIVING, LP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/22/2022 |
| CHANCE, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2020 |
| TAYLOR, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/01/2020 |
| THEMER, DIANE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/13/2021 |
| CAMPBELL, SCOTT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/12/2025 |
| FISHER, JAMES | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/12/2025 |
| LANGDON, THOMAS | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/18/2025 |
| MCGEHEE, WILLIAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/18/2025 |
| LIFETIME WELLNESS, LTD. | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| MARTUS FINANCIAL SERVICES, INC. | Organization | ADP OF THE SNF | — | since 12/31/2023 |
| PHARMERICA DRUG SYSTEMS LLC | Organization | ADP OF THE SNF | — | since 08/29/2017 |
| REHAB PRO LP | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| BRANSON, KEISHA | Individual | ADP OF THE SNF | — | since 08/19/2022 |
| MILLS, JON | Individual | ADP OF THE SNF | — | since 03/01/2018 |
CMS files one row per role, so the 24 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OK
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oklahoma Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375527. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.