Garland Road Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Garland Road Nursing & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF656Jan 8, 2026

  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. […]

• Immediate jeopardy, patternF689Jan 8, 2026

  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… […]

• No harm, potential for more than minimal, widespreadF809Jan 6, 2023

  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… […]

• No harm, potential for more than minimal, widespreadF812Jan 6, 2023

  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. […]

• No harm, potential for more than minimal, patternF657Nov 21, 2025

  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. […]