Morada Lawton

What the state also noted

• — The April 2026 medication citations are significant: a resident's cyclosporine eye drops, blood pressure, cholesterol, antidepressant, acid-reducer, and vitamin D doses were repeatedly missed through March and early April 2026 because pharmacy refills were not obtained (cited as a pattern affecting several residents), and thyroid medication scheduled for 6:00 a.m. was routinely given hours late. The certified medication aide told inspectors they call the pharmacy for refills but 'do not document it on a log or in the medical record,' and the executive director said they were not aware the resident was out of medications.
• — Also cited in April 2026: the facility did not report an abuse allegation to the state as required. A nurse aide told inspectors the resident reported a CNA 'had swatted the resident's hands and talked to them like a dog'; the resident told the surveyor a staff member 'had slapped their hand and hollered' at them; a family member independently corroborated it; the facility suspended a CNA. The executive director confirmed on 04/09/26 they 'had not reported the allegation to the state.' Separately, a resident on a soft, bite-size diet was served a whole hamburger and chips.
• — The center's plan of correction for the April 2026 citations was returned by the state as unacceptable twice (once on June 11, 2026 for a missing plan on the medication-availability citation, once on June 18, 2026 because the medication plan had no staff education component) before being resubmitted.
• — Complaint volume is high — roughly 30 complaint investigations across these four surveys, including 13 folded into the October 2025 relicensure survey and 8 in April 2026.
• — The October 2025 Statement of Deficiencies is largely missing from this bundle's OCR (the text cuts off at 'continuation sheet 2 of 17'). Only one citation from that survey is readable. The 13 complaints folded into that survey alleged, among other things, physical and verbal abuse, elopement, failure to prevent falls with major injury, misappropriation of residents' property and of medications, administering incorrect medication as retaliation, retaliation against families who voiced grievances, and bed bug harborage. Because 15 of the 17 pages are unreadable, it cannot be determined which of these were cited, and the October 2025 findings should not be assumed minor.
• — Deficiencies were cited at three of the four surveys reviewed (December 2024, October 2025, and April 2026). Only the December 2025 complaint investigation was clean.
• — Medication availability is a REPEAT deficiency, not a one-time lapse. It was cited in December 2024 — 14 physician-ordered doses not given in November 2024, 35 not given in December 2024, the resident out of memantine for three days, and the health and wellness director reporting 'there was no system in place to get medications if their pharmacy did not deliver' — and cited again sixteen months later in April 2026.
• — December 2024 elopement findings are directly relevant to memory care families: Resident #4 scored 40 on the Elopement Risk Evaluation ('40 and above high risk for elopement') and was found knocking on an egress door at the end of the 200 hall at about 3:20 a.m. on 11/25/24. The plan of care was never updated afterward, the hourly safety checks ordered in response were largely uninitialed on the treatment administration record, and the responsible family member was never actually reached — the health and wellness director confirmed the aide 'actually did not speak with Resident #4's family member.' The family told inspectors they were unaware the elopement had happened.
• — December 2024 also cited kitchen sanitation, at a scope the state records as a pattern affecting several residents: a trash can without a lid, a scoop stored inside the flour, a wet scoop on top of the ice machine, two boxes of thickened liquid stored on the floor, and a nurse aide plating soup with their hair outside the hairnet.
• — Pest control: the December 2024 complaint alleged an ineffective pest control program generally, and inspectors saw no bugs and reviewed pest control records and invoices. A bed bug harborage allegation was then raised again in October 2025, in the survey whose findings are unreadable — so pest control cannot be presented as a settled strength.
• — OSDH reports for this facility list allegations and then list citations; they do not label individual allegations 'substantiated' or 'unsubstantiated.' The absence of a citation on a particular tag is therefore NOT a finding that the allegation was false, and should never be presented to families as one.