Grace Skilled Nursing And Therapy Jenks
Inspection history, citations, penalties and survey trends for this long-term care facility in Jenks, Oklahoma.
- Location
- 711 North 5th Street, Jenks, Oklahoma 74037
- CMS Provider Number
- 375358
- Inspections on file
- 31
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Grace Skilled Nursing And Therapy Jenks during CMS and state inspections, most recent first.
The facility did not ensure that wound care was properly documented for two residents with severe cognitive impairment and pressure ulcers. Despite physician orders specifying wound care regimens, treatment administration records showed missing documentation for several scheduled wound care dates. Nursing staff confirmed that wound care was performed but not consistently recorded, resulting in incomplete medical records.
A resident's room was found to have broken mini blinds and multiple areas of missing paint, with the resident stating these issues had persisted for three years. Staff interviews revealed uncertainty about responsibility and whether maintenance had been notified, despite maintenance being designated for such repairs.
A resident with severe cognitive impairment and a feeding tube did not receive a prescribed nutritional supplement because the order was not entered into the medication/treatment administration record. Staff interviews confirmed the supplement was not administered, and the omission was not detected during daily audits by nursing leadership.
A resident with intact cognition and a history of stroke reported that their television stopped working after a power outage, displaying only sound and no picture. The facility provided a loaner television but did not replace the damaged one, with the administrator stating that replacement of personal property was not the facility's responsibility according to the admission agreement. No grievance was filed regarding the incident.
Two residents identified as high fall risk did not consistently receive fall prevention interventions as outlined in their care plans. One resident, with a history of falls and fractures, repeatedly did not have a fall mat at the bedside as required. Another resident, with severely impaired cognition and a recent fall resulting in injury, had a fall mat placed under the bed rather than at the bedside. Staff interviews and observations confirmed inconsistent implementation of these safety measures.
A resident with severe cognitive impairment was left calling out for help to use the bathroom without timely assistance, as staff were not available to respond promptly. Multiple CNAs and an LPN confirmed that staffing levels were inadequate to answer call lights within the expected five-minute timeframe.
A resident with intact cognition and a history of stroke was placed on a soft diet with thickened liquids without clear justification, despite expressing a preference for a regular diet and no history of choking. Facility staff could not trace the origin of the diet order, did not provide a swallow evaluation, and did not honor the resident's dietary choices, citing physician orders and lack of waivers outside of hospice care.
The facility failed to secure chemicals in three of its eight halls, with unlocked closets containing various cleaning agents and chemicals labeled to be kept out of reach of children. Observations revealed that the 800 hall linen closet, 700 hall housekeeping closet, and 100/200 hall central supply closet were all unsecured, contrary to the facility's policy. Interviews with the DON and administrator confirmed lapses in securing these areas, posing potential safety hazards.
The facility failed to label and date food items in refrigerator #1, including sliced cheese, diced onion, diced tomatoes, diced honeydew melon, and tuna salad. The dietary manager was unaware of why the items were not labeled or dated, despite acknowledging that they should be. The Director of Nursing noted that 122 residents received nourishment from the kitchen.
A resident with dementia had a significant change assessment completed but not transmitted within the required timeframe. The assessment was completed but transmitted late due to the absence of an MDS coordinator, despite monitoring by the corporate office.
A resident with intact cognition reported neglect by a nurse aide, who failed to provide care after turning off the call light. The complaint was reported to the ADON and administrator, but no thorough investigation or documentation was completed, and the issue was not addressed.
A resident with a history of constipation went five days without a bowel movement, leading to hospitalization for stercoral colitis. The facility failed to follow its policy of assessing and notifying the physician after three days without a bowel movement. The electronic health record system did not alert staff, and the resident's condition was not addressed until they were in significant pain. Staff interviews revealed a lack of awareness and adherence to procedures, resulting in the resident's hospitalization.
A resident with seizures experienced a significant medication error when an ACMA incorrectly measured Dilantin using medication cups instead of a syringe, leading to a potential overdose. The DON confirmed that the medication should have been measured with a syringe, and a discrepancy in the Dilantin count was not reported, highlighting lapses in communication and monitoring.
The facility failed to date medications when opened across four medication and treatment carts. Observations revealed that various medications, including inhalers, insulin, eye drops, and test strips, were opened but not dated. The DON confirmed that staff were expected to date these items, and a consultant pharmacist audited the carts monthly.
A resident with a history of constipation went five days without a bowel movement, yet the attending physician was not notified as required by facility policy. The resident's condition was only addressed when they were sent to the hospital. Both the DON and an RN acknowledged the oversight, with the DON realizing the issue upon returning from vacation.
A resident with intact cognition reported neglect when a nurse aide failed to provide care after turning off the call light. The resident filed a complaint with the ADON, who reported it to the administrator. However, the facility did not report the incident to the OSDH, as required by their policy, because the administrator did not believe it constituted abuse.
A facility failed to maintain accurate medication records and reconcile controlled drugs for a resident prescribed oxycodone for pain management. Discrepancies were found between the Medication Administration Records and narcotics sheets, with missing documentation contributing to the inconsistency. An investigation revealed that CMAs and LPNs often documented only on narcotic sheets, neglecting electronic records, but found no evidence of medication diversion.
A resident with dementia and COPD, requiring supervision while smoking, was left unsupervised and attempted to smoke with oxygen on, resulting in a fire. The resident sustained severe burns and was transported to a hospital burn center, where they later passed away. Staff confirmed the lack of supervision during the incident.
The facility failed to ensure that dependent residents were offered or provided showers as required. One resident with a left femur fracture received only one shower over a two-week period, and another resident with right and left humerus fractures received only one shower since admission. Despite monitoring and staffing efforts, the facility did not consistently offer or provide showers, as evidenced by the lack of documentation and staff statements.
The facility failed to monitor weights as ordered for two residents, leading to undocumented weight values and significant weight loss. One resident with osteoporosis and another with humerus fractures experienced unmonitored weight changes, with the latter losing 13 pounds in 14 days.
The facility failed to ensure snacks were provided to residents as required, particularly affecting four residents with specific medical conditions. Interviews with staff revealed inconsistencies in the process of offering snacks, and there was confusion about where to document snack distribution. The lack of a consistent and documented process for offering snacks, especially to diabetic residents with specific orders for bedtime snacks, led to the identified deficiencies.
A facility failed to notify a physician of a resident's low blood pressure readings as required by a physician's order. The resident, with diagnoses including congestive heart failure and chronic kidney disease, had blood pressure readings outside the specified range on two occasions. An LPN confirmed they did not call the physician, and the nurse practitioner identified the issue during a clinical record review, leading to the resident being sent to the hospital.
The facility failed to ensure wound care was provided as ordered for a resident with a sacral pressure ulcer. Wound care was not documented as completed multiple times in March and April 2024, and the wound nurse and DON could not explain the lapses.
The facility failed to ensure proper pain management for a resident with a sacral pressure wound and cervical spine fractures. Despite a physician's order for pain medication, staff did not monitor or document its effectiveness, as confirmed by interviews with a CMA, an LPN, and the DON.
Failure to Document Wound Care for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper documentation of wound care for two of three sampled residents with pressure ulcers. For one resident with severe cognitive impairment and multiple pressure ulcers, physician orders specified wound care regimens for different wounds, including cleansing and dressing changes on specific days and shifts. However, review of the treatment administration records revealed missing documentation for several scheduled wound care dates and shifts. Interviews with wound care nurses confirmed that while the wound care was reportedly performed, it was not consistently documented in the treatment administration records as required. Another resident, also with severe cognitive impairment and a stage 3 pressure ulcer, had physician orders for wound care on designated days. The treatment administration record for this resident similarly lacked documentation for several scheduled wound care dates. Nursing staff acknowledged that the wound care was completed but not recorded. The Director of Nursing stated that daily audits and weekly monitoring of treatment records were in place, but the documentation failures persisted during the review period.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was observed to have two broken and missing slats on the mini blinds, as well as a one foot by one foot area of missing paint on the North wall and several smaller areas of missing paint along the North and East walls. The resident reported that both the broken blinds and missing paint had been present for the three years they had resided in the facility. When interviewed, a CNA was unsure who was responsible for addressing these issues, while an LPN stated that maintenance was responsible but was unaware if maintenance had been informed of the room's condition. The maintenance supervisor confirmed responsibility for repairs, and the administrator stated that such issues should be reported to maintenance for resolution.
Failure to Administer Ordered Nutritional Supplement via Feeding Tube
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a nutritional supplement ordered for a resident with severe cognitive impairment and a feeding tube was provided as prescribed. The resident, who had a diagnosis of dementia and was at risk for nutritional problems and weight fluctuations, was recommended by the dietician to receive a 2.0 cal nutritional supplement, 30cc twice daily via feeding tube. This order was confirmed by both a nurse note and a physician order. However, review of the medication/treatment administration records for the relevant period showed that the order for the nutritional supplement was not entered, and thus was not administered to the resident. Interviews with staff, including an LPN, an ACMA, the ADON, and the DON, confirmed that the supplement order was not present on the medication/treatment record and had not been given. The ADON stated that when the order was entered into the electronic clinical record, it did not carry over to the administration record. The DON acknowledged that despite daily audits of new orders, the omission of the nutritional supplement from the administration record was not identified by the charge nurse or ACMA, resulting in the resident not receiving the ordered supplement.
Failure to Replace Damaged Resident Property After Power Outage
Penalty
Summary
The facility failed to ensure the replacement of a resident's damaged personal property, specifically a television, after a power outage rendered it unusable. The resident, who had intact cognition and a history of stroke, reported that following the outage, their television would only produce sound with no picture. The facility took the resident's television and provided a loaner but did not replace the damaged item. The administrator stated they were unaware of the issue and indicated that, according to the admission agreement, the facility does not replace personal property damaged under such circumstances. There was no record of a grievance filed by the resident regarding the television.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident, repeated observations over two days revealed that a fall mat, which was an intervention specified in the care plan following a previous unwitnessed fall resulting in fractures, was not present at the bedside. Staff interviews indicated that the resident was on hospice and unable to move independently, but the care plan still included the use of a fall mat as a preventive measure. The care plan also listed other interventions such as keeping the call light within reach, using positioning bars, and frequent checks, but the absence of the fall mat was consistently noted during multiple observations. For another resident, who was assessed as a high fall risk with severely impaired cognition, the fall mat was observed to be under the bed rather than positioned at the bedside as intended. This resident had a recent history of a fall resulting in a head laceration and abrasions, despite the fall mat being in place at the time. Staff interviews revealed some uncertainty about the exact placement of the fall mat and the circumstances of the fall, with one CNA stating they did not know why the fall mat was not present at the bedside during one observation. The care plan for this resident included multiple interventions such as a concave mattress, fall mat at bedside, and keeping the bed in the lowest position, but the implementation of these interventions was inconsistent. The deficiencies were identified through direct observation, record review, and staff interviews, which demonstrated that the facility did not consistently ensure that fall prevention interventions were in place as specified in the residents' care plans. Both residents had documented histories of falls and were assessed as high risk, yet the required safety measures were not reliably implemented, leading to a failure to provide adequate supervision and prevent accident hazards.
Insufficient Staffing Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of a resident with severe cognitive impairment. On the observed date, the resident was repeatedly calling out for help to use the bathroom, but a CNA who was present in the hallway did not check on the resident and instead retrieved a dirty linen cart. The resident continued to call for assistance until an LPN was informed and responded. The resident's assessment indicated a BIMS score of 06, signifying severe cognitive impairment, and required supervision for transfers and partial to moderate assistance with toilet hygiene. Multiple CNAs interviewed stated that call lights should be answered within five minutes, but they did not feel there was enough staff to meet this expectation, confirming delays in responding to residents' needs due to insufficient staffing.
Failure to Honor Resident's Right to Dietary Choice
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding their diet. A resident with a history of stroke and aphasia, but with intact cognition, was observed consuming soda in their room and reported dissatisfaction with being placed on a soft diet with thickened liquids. The resident stated they had not experienced choking and had not undergone a swallow evaluation at the facility, being told by staff that insurance would not cover it. The resident also reported consuming regular food brought by friends and had previously eaten a regular diet at home and upon initial admission. Facility staff, including the ADON, social services director, and administrator, were unable to clearly identify the origin of the soft diet order, with some suggesting it may have been a transcription error or related to a previous hospice waiver. The medical director believed the order was due to a stroke and possible dysphagia, but there was no documented diagnosis of dysphagia or incidents of choking. The facility did not offer waivers for diet preferences outside of hospice care, and staff indicated they would not question the physician's order or seek justification, resulting in the resident's dietary preferences not being honored.
Failure to Secure Chemicals in Facility
Penalty
Summary
The facility failed to ensure that chemicals were secured in three of the eight halls observed, specifically the 100/200 hall, 700 hall, and 800 hall. The facility's housekeeping policy mandates that all harmful chemicals must be stored in a locked storage at all times. However, during observations, it was found that the 800 hall linen closet was unlocked and contained chemicals such as periwash and shaving cream, both labeled to be kept out of reach of children. Similarly, the 700 hall housekeeping closet was unlocked and contained various cleaning chemicals, including floor finish, spot cleaner, and stain remover, all labeled with warnings to keep out of reach of children. Additionally, the 100/200 hall central supply closet was found unlocked with the latch taped open, containing iodine swab sticks labeled to be kept out of reach of children. Interviews with the Director of Nursing (DON) and the administrator revealed that the floor technician had not locked the 700 hall housekeeping closet after use, and the 800 hall linen closet did not have a functioning lock. The DON also noted that the tape on the latch of the 100/200 hall central supply closet was inappropriate and should not have been used to prevent the door from locking. The administrator confirmed that the green liquid found in a bottle labeled as purified drinking water in the 700 hall housekeeping closet was not water, and the door should have been locked. These observations and interviews indicate a failure to adhere to the facility's policy on securing chemicals, posing potential safety hazards.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were labeled and dated, as observed during a survey. Specifically, on September 16, 2024, at 8:50 a.m., several food items in refrigerator #1 were found without labels or dates. These items included two plastic containers with sliced cheese, one plastic container with diced onion, one plastic container with diced tomatoes, one plastic container with diced honeydew melon, a paper plate with sliced cheese, and an opened container of tuna salad. The Director of Nursing identified that 122 residents received nourishment from the kitchen. When questioned, the dietary manager stated they did not know why the containers were not labeled or dated, but acknowledged that they should be.
Failure to Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to ensure timely transmission of assessments for a resident diagnosed with dementia. The significant change assessment for this resident had an Assessment Reference Date (ARD) of June 20, 2024, and was completed on July 4, 2024. However, the assessment was not transmitted until September 16, 2024, which was well beyond the required 7-day transmission period. During this time, the facility lacked an MDS coordinator, and the corporate MDS coordinator was assisting with MDS completion and transmission. Despite monitoring occurring twice a week by both the facility's MDS coordinator and the corporate office, the significant change assessment was transmitted late.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident with intact cognition and no cognitive impairments. The resident had complained about a nurse aide not providing adequate care, specifically mentioning an incident where the aide turned off the call light without providing care and promised to return but did not. The resident reported this issue to the Assistant Director of Nursing (ADON) approximately two weeks prior to the survey, but no action was taken to address the complaint. The ADON confirmed the complaint was reported to them and that they had informed the administrator, but no documentation or investigation was completed. The administrator acknowledged receiving the grievance form and speaking to one aide but did not conduct a comprehensive investigation, such as interviewing the roommate or other residents. The administrator also failed to document the interview with the aide, citing the resident's history of complaints as a reason for not taking further action.
Failure to Address Resident's Constipation Leads to Hospitalization
Penalty
Summary
The facility failed to notify the attending physician of a resident's prolonged constipation, which lasted five days without a bowel movement, leading to the resident's hospitalization for stercoral colitis. The facility's policy required assessment and physician notification after three days without a bowel movement, but this was not followed. The resident, who had a history of constipation and was moderately impaired cognitively, had an as-needed order for a laxative but did not receive it until the fifth day of constipation. The documentation showed that the resident had a bowel movement on one day and then went five days without another, during which time the facility did not assess the resident or notify the physician. The electronic health record system, which was supposed to flag such issues, did not alert the staff, and the resident's condition was not addressed until they were in significant pain and requested to go to the hospital. The resident was eventually sent to the hospital, where they were diagnosed with stercoral colitis due to longstanding constipation. Interviews with staff revealed that the facility's procedures for monitoring and addressing constipation were not followed. The CNA and CMA were unaware of the resident's constipation, and the RN admitted that the system did not flag the issue, leading to a lack of assessment and notification. The DON confirmed that the facility's policy was not adhered to, and there were no assessments or notifications documented until the resident was hospitalized.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during medication administration. The resident, who had a diagnosis of seizures, was prescribed Dilantin, an anti-epileptic medication, to be administered via a peg tube. The physician's order specified a dosage of 125 mg/5 ml, to be given as 8 ml three times a day. However, during an observation, a medication administration error was noted when an ACMA incorrectly measured the medication using two separate medication cups instead of a syringe, resulting in an incorrect dosage. The ACMA mistakenly believed that the markings on the medication cup indicated 0.5 ml when it actually indicated 5 ml, leading to a potential overdose. The facility's Director of Nursing (DON) later confirmed that the medication should have been measured using a syringe if the correct dosage was not clearly marked on the medication cup. Additionally, a discrepancy was found in the count record of the Dilantin bottle, which should have contained 312 ml but only had 300 ml. The DON was not informed of this discrepancy by the CMAs, indicating a lapse in communication and monitoring of medication administration. This series of errors and miscommunications contributed to the significant medication error for the resident.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to ensure that medications were dated when opened, as observed during a survey. This deficiency was noted across four medication and treatment carts, specifically the 200 hall medication cart, 200/400 hall treatment cart, 100/300 hall treatment cart, and the 600 hall medication cart. During the survey, it was observed that a Ventolin inhaler for a resident on the 200 hall medication cart was opened but not dated. Similarly, on the 200/400 treatment cart, several medications including insulin lispro, fluticasone propionate inhaler, Trelegy inhaler, albuterol inhaler, and a bottle of glucometer test strips were found opened without dates. Further observations revealed that on the 100/300 hall treatment cart, a vial of lidocaine and a house stock vial of sterile water were opened but not dated. On the 600 hall medication cart, Refresh eye drops for two residents and polyvinyl alcohol liquifilm tears for another resident were also opened without being dated. The Director of Nursing (DON) confirmed that staff were expected to date medications such as eye drops, nose sprays, insulin, inhalers, and glucometer test strips when opened, and mentioned that the consultant pharmacist conducted monthly audits of the medication carts.
Failure to Notify Physician of Resident's Constipation
Penalty
Summary
The facility failed to notify the attending physician of a resident's constipation, which lasted for five days without a bowel movement. The facility's policy requires physician notification if a resident has not had a bowel movement for three days. Despite this policy, there was no documentation indicating that the physician was informed of the resident's condition until the resident was sent to the hospital. The resident, who had a diagnosis of constipation and was receiving orthopedic aftercare, was documented to have a bowel movement on one day, followed by a five-day period without any bowel movements. During this time, the resident was noted to be constipated, yet the physician was not notified. The Director of Nursing (DON) and RN #1 both acknowledged the oversight. RN #1 was unaware of the resident's constipation and did not notify the physician. The DON realized the issue upon returning from vacation, noting that the resident's condition had not been addressed. The physician was eventually notified on the day the resident was sent to the hospital, which was several days after the initial period of constipation began. This delay in communication and failure to follow the facility's policy contributed to the deficiency identified in the report.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the Oklahoma State Department of Health (OSDH) for a resident who was reviewed for neglect. The facility's policy on Resident Abuse, Neglect, and Misappropriation of Property requires that all allegations and incidents of abuse and neglect be reported to appropriate federal and state agencies, including OSDH. However, in this case, the facility did not report the allegation of neglect involving a resident who had complained about a nurse aide not providing adequate care. The resident, who had intact cognition and no cognitive impairments, reported that after turning on their call light, an aide shut it off without providing care and did not return as promised. The resident filed a complaint with the Assistant Director of Nursing (ADON) about the lack of care, but no action was taken. The ADON confirmed the complaint was reported to the administrator, and a grievance form was filled out, but there was no documentation of the report to OSDH. The administrator stated they only reported to OSDH if they felt abuse occurred, and in this case, they did not believe it constituted abuse.
Medication Record Discrepancy and Reconciliation Failure
Penalty
Summary
The facility failed to maintain accurate medication records and reconcile controlled drugs for a resident with a diagnosis of an unspecified fracture of the right pubis. A physician's order prescribed oxycodone, an opioid medication, to be administered as needed for pain. However, discrepancies were found between the Medication Administration Records (MARS) and the narcotics sheets. The MARS documented 18 doses of oxycodone administered, while the narcotics sheets indicated 49 doses were given over the same period. The first page of the narcotics count sheet was missing, contributing to the inconsistency in records. Interviews revealed that Certified Medication Aides (CMAs) and Licensed Practical Nurses (LPNs) were responsible for counting narcotics at the end of each shift. However, they often documented medication administration only on the narcotic sheets, neglecting the electronic records. An investigation by the corporate nurse into a missing medication card found no evidence of medication diversion but highlighted documentation issues. Despite efforts to locate the missing narcotic count sheet, it was not provided to the survey team by the end of the survey.
Resident Smoking Incident Leads to Fire
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who required supervision while smoking, leading to a serious incident. The resident, who had dementia and chronic obstructive pulmonary disease, was moderately impaired in daily decision-making and required oxygen therapy. Despite a physician's order for oxygen use and a checklist indicating the need for supervision while smoking, the resident was left unsupervised and attempted to smoke with their oxygen on, resulting in a fire. On the day of the incident, a nurse was notified by a CMA that the resident was on fire. Upon reaching the scene, the nurse found the resident in a wheelchair that appeared burned, with multiple areas of burned skin. The resident was conscious but complaining of difficulty breathing and was transported to a hospital burn center. Staff interviews confirmed that no supervision was provided at the time of the incident, and the resident was not being monitored while smoking. The facility's investigation revealed that the resident was not supervised during the smoking incident. Staff members, including a CMA and a CNA, reported hearing about the fire and attempting to assist the resident. The administrator acknowledged the lack of supervision and noted that fire blankets had been ordered but not yet received. The resident ultimately passed away at the hospital due to the injuries sustained.
Failure to Provide Required Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents were offered or provided showers as required. Resident #2, who had a left femur fracture and required moderate assistance with bathing, was documented to have received only one shower between 11/20/23 and 12/02/23. Similarly, Resident #4, who had right and left humerus fractures and required maximum assistance with bathing, was documented to have received only one shower since their admission on 04/01/24. The DON and ADON monitored showers during Q2 meetings and asked residents on Fridays if their showers had been completed. Despite realizing that showers were not being completed and staffing shower aides in January 2024, the facility still failed to ensure that showers were consistently offered or provided, as evidenced by the lack of documentation in the electronic health records and the statements from the Regional Nurse and DON.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure weights were monitored as ordered by the physician for two residents. Resident #8, who had diagnoses including osteoporosis, was at risk for a nutritional problem related to anemia and GERD. The care plan required weekly weights, but the electronic health record did not contain documentation of the weight values on several dates. The DON acknowledged that weekly weights should be documented in the electronic health record but noted there might not be a space to document them on the treatment record. Resident #4, who had diagnoses including right and left humerus fractures, was at risk for unplanned weight loss. The care plan included monitoring for signs of malnutrition and providing a regular diet with superceral at breakfast. However, Resident #4 reported not eating breakfast and had unintentionally lost weight since admission. The resident's weight dropped from 136 pounds to 123 pounds in 14 days. The DON confirmed the lack of further documentation of weight values for both residents.
Failure to Provide Snacks to Residents
Penalty
Summary
The facility failed to ensure snacks were provided to residents as required, particularly affecting four residents with specific medical conditions. Resident #2, diagnosed with diabetes mellitus, had no documentation of snacks being offered or provided from 11/20/23 through 11/30/23 and on 12/01/23. Resident #6, also diagnosed with diabetes mellitus, had no record of snacks being offered or provided from 04/09/24 through 04/18/24, and stated on 04/19/24 that they were unaware snacks were available. Resident #10, diagnosed with GERD and cognitively intact, was documented to have been offered and accepted a snack only once during a 30-day period. This resident had to wheel themselves to the nurses station to obtain snacks, as staff did not offer them proactively. Resident #9, diagnosed with cerebrovascular disease, reported receiving snacks but not always eating them. The electronic clinical record showed snacks were offered only seven days out of a 30-day review period, with no documentation of refusals. Interviews with staff revealed inconsistencies in the process of offering snacks. The dietary manager stated snacks were delivered to the nurses stations at specific times, but residents had to go to the nurses station to obtain them. CNAs confirmed that they did not routinely offer snacks to residents, and there was confusion about where to document snack distribution. The DON stated that CNAs were supposed to pass snacks at bedtime and that bed-bound residents needed to use their call light to request snacks. The lack of a consistent and documented process for offering snacks, especially to diabetic residents with specific orders for bedtime snacks, led to the identified deficiencies.
Failure to Notify Physician of Change in Resident's Status
Penalty
Summary
The facility failed to ensure notification to the physician of a change in status for one resident reviewed for notification of change. The resident had diagnoses including congestive heart failure, chronic kidney disease, and a sacrum pressure ulcer. A physician's order required blood pressure monitoring twice a day and to report to the physician if the systolic blood pressure was greater than 170 or below 90, and if diastolic blood pressure was greater than 100 or below 70. On two occasions, the resident's blood pressure readings were outside the specified range, but there was no documentation that the physician had been notified. An LPN confirmed they had not called the physician, and the nurse practitioner stated they were not notified via telephone of the low blood pressure. The nurse practitioner identified the low blood pressure during a review of the clinical record, and the resident was subsequently sent to the hospital for evaluation and treatment.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was provided as ordered for a resident with a sacral pressure ulcer. The resident had a physician's order to cleanse the sacrum with normal saline, apply medihoney/durafiber ag (silver), and cover with bordered foam daily, but the Treatment Administration Record for March 2024 revealed that wound care was not documented as completed eight times out of 22 opportunities. Additionally, a physician's order to paint the left heel with skin prep and leave it open to air every shift and as needed was not documented as completed nine times out of 31 opportunities. Another order to cleanse the sacrum wound with normal saline, pack it with dakins soaked gauze, cover with an ABD pad, and secure with tape daily was not documented as completed one time out of eight opportunities in April 2024. The wound nurse was unable to explain why the wound care was not documented, and the DON stated that corporate staff monitored wound treatments and usually received reports if treatments were missed.
Failure to Document Pain Management Effectiveness
Penalty
Summary
The facility failed to ensure proper pain management for a resident with a sacral pressure wound and cervical spine fractures. Despite a physician's order to administer hydrocodone/acetaminophen every six hours for pain, the Medication Administration Record and electronic health record lacked documentation of the medication's effectiveness. Interviews with a CMA and an LPN revealed that staff did not monitor or document the effectiveness of routine pain medication, although they verbally inquired about it. The DON confirmed that pain assessments were supposed to be completed every three months and that charge nurses were to monitor effectiveness one hour after administration, but this was not documented in the clinical record.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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