Garland Road Nursing & Rehab Center

Inspectors wroteOn 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. [...]

Inspectors wroteOn 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.