Garland Road Nursing: Care Plan Delays Found - OK
Resident #5 was discovered lying clothed in Resident #11's bed on July 8, according to a facility incident report. Both residents were fully clothed when found. Staff removed Resident #5 and notified the physician, director of nursing, and left a voicemail for family.
The wandering continued.
On September 18, Resident #4 found Resident #5 in their room going through their roommate's closet. Resident #4 told inspectors on September 23 that Resident #5 kept coming into their room and closet, and they had requested a room change to feel safe.
CNA #2 described another incident where Resident #5 was found "lying in Resident #11's bed sleeping fully clothed half on the bed and half on the floor." Police were called, family was notified, and Resident #11's room was changed.
But Resident #5 continued the pattern. "Resident #5 continues to go into the same room where Resident #4 is now located," CNA #2 told inspectors. "There has been nothing done to prevent Resident #5 from going into other resident's room."
The facility's response was minimal. RN #1 said the intervention for Resident #5's wandering was simply to "redirect the resident." The assistant director of nursing confirmed they moved Resident #11's room after the bed incident but took no other action.
Director of Nursing acknowledged the failures during the September inspection. "The interdisciplinary team should have met and care planned interventions after each incident of wandering," the DON told inspectors. "Resident #5's care plan was not updated with interventions to prevent wandering after 06/20/25."
Family members expressed concern about the repeated incidents. Family representative #3 said they were notified about Resident #5 being found in Resident #11's bed, and that police were called. The physician had been adjusting Resident #5's Seroquel medication because the resident was "becoming increasingly confused in the evening."
Family representative #4 confirmed they consented to Resident #11's room change after the July incident and said Resident #11 was not harmed.
The inspection revealed systematic gaps in the facility's approach to resident safety. Corporate nurse #1 admitted the facility had no policy for ensuring care plans were revised after incidents. Instead, they said the facility follows the RAI manual without specific protocols for updating safety interventions.
Resident #5's medical records showed diagnoses including type 2 diabetes, pseudobulbar affect, and bradycardia. Their September assessment indicated significantly impaired cognition and inability to participate in cognitive testing. They required assistance with transfers and used a wheelchair for mobility.
The affected residents lived with varying levels of vulnerability. Resident #11, who was found in bed with the wandering resident, had significantly impaired cognition and could only smile without responding to questions. Resident #4, whose room and belongings were repeatedly accessed, had intact cognition with a cognitive score of 14.
Multiple staff members confirmed the ongoing nature of the problem. The assistant director of nursing said Resident #5 "was reported to wander into Resident #11's room and get in their bed and fell asleep." The director of nursing described "behaviors of wandering in and out of other resident's room" as an established pattern.
Despite the July incident requiring police notification and the September complaint that triggered the inspection, the facility made no systematic changes to prevent future wandering episodes. The pattern continued with Resident #5 accessing the new room where Resident #4 had been moved.
The inspection found the facility failed to ensure residents' right to personal privacy and safety from other residents' intrusive behaviors. The lack of updated care planning left vulnerable residents exposed to continued unauthorized room entries while staff relied solely on verbal redirection of a resident with significantly impaired cognition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Garland Road Nursing & Rehab Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Garland Road Nursing & Rehab Center in Enid, OK was cited for violations during a health inspection on November 21, 2025.
Resident #5 was discovered lying clothed in Resident #11's bed on July 8, according to a facility incident report.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.