Garland Road Nursing & Rehab Center
Garland Road Nursing & Rehab Center in Enid, OK — inspection on November 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
assessment, dated 07/10/25, showed their cognition was intact with a BIMS score of 14.
The assessment showed the resident was admitted with diagnoses which included acute kidney failure, nontraumatic intracerebral hemorrhage, and type 2 diabetes.Resident #4's nurses notes, dated 09/18/25, read in part, .Late Entry for 09/1825 05:15 AM resident was upset to find another resident in her room going through [her] roommates' closet. 3. On 09/24/25 at 9:35 a.m., Resident #11 was observed lying in bed with head of bed elevated at twenty degrees.
Their call light was in reach, the bed was low, and a fall mat was in place.
The resident only smiles and did not respond to any questions. A facility document titled Incident Case report, dated 07/08/25, read in part, .Resident found in female residents' room [they] had fallen asleep with [their] on [other residents] bed.
Both residents fully clothed.
Resident removed from [gender withheld] residents' bed and took back to [their] own room. PCP, DON, and left voice mail on [family representatives] phone to call back.Resident #11s annual assessment, dated 09/01/25, showed their cognition was significantly impaired and was unable to participate in the BIMS assessment.
The assessment showed Resident #4 was dependent for toileting and hygiene and required supervision or touching assistance for bed mobility.
The assessment showed the resident required partial to moderate assistance with transfers and they used a wheelchair for mobility.
The assessment showed Resident #4 had diagnoses which included type 2 diabetes, pseudobulbar affect, and bradycardia. On 09/23/25 at 2:51 p.m., Resident #4 stated Resident #11 was coming into their room and their closet. Resident #4 stated they requested to be moved rooms to prevent it from happening again and feels safe in the facility. On 09/24/25 at 10:41 a.m., family representative #3 stated they were notified Resident #5 was found lying clothed in Resident #11's bed.
They stated the police were called and the physician has been adjusting resident #5's Seroquel due to the resident becoming increasingly confused in the evening. On 09/24/25 at 11:20 a.m., CNA #2 stated Resident #5 was found lying in Resident #11s bed sleeping fully clothed half on the bed and half on the floor. CNA #2 stated Resident #11's room was changed, the police were called, family was notified, and a report was made. CNA #2 stated Resident #5 continues to go into the same room where Resident #4 is now located. CNA #2 stated that there has been nothing done to prevent Resident #5 from going into other resident's room. On 09/09/25 at 1:30 p.m., RN #1 stated Resident #5 had wandering behaviors which included wandering into other resident rooms. RN #1 stated the intervention to prevent the resident wandering into other residents' room was to redirect the resident. On 09/09/25 at 2:12 p.m., the ADON stated Resident #5 was reported to wander into Resident #11's room and get in their bed and fell asleep.
The ADON stated they moved Resident #11's room. On 09/24/25 at 3:20 p.m., the DON stated Resident #5 has behaviors of wandering in and out of other resident's room.
The DON stated there was an incident on 07/08/25 where Resident #5 was found sleeping in Resident #11's bed with Resident #11.
The DON stated there was another incident recently when Resident #5 wandered into Resident #4's roommates closet.
The DON stated the interdisciplinary team should have met and care planned interventions after each incident of wandering.
The DON stated Resident #5's care plan was not updated with interventions to prevent wandering after 06/20/25. On 09/24/25 at 4:24 p.m., family representative #4 stated they were notified on 07/08/25, Resident #11 was found in bed with Resident #11.
Family representative #4 stated the police were notified, they consented to Resident #11's room being changed, and Resident #11 was not harmed.
On 09/29/25 at 5:15 p.m., corporate nurse # 1 stated the facility did not have a policy for ensuring care plans were revised and reevaluated after an incident.
Corporate nurse #1 states the facility follows the RAI manual.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.