Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
Failure to provide ordered ROM services for two residents with documented ROM impairments. Both residents had BIMS scores of 15 and care plans directing active and passive ROM to affected extremities, but the EHR showed no ROM documentation for the review periods. One resident reported limited ROM in both arms and said they had not received ROM services for months; staff stated restorative services had not started because a restorative aide had not been hired, and the DON said the facility did not have a restorative program in place even though CNAs were expected to complete ROM.
Incomplete Pre- and Post-Dialysis Assessments: Two residents receiving dialysis had missing or inaccurate dialysis documentation. One resident with ESRD and a dialysis port had repeated forms with outdated vital signs, incorrect thrill/bruit documentation, and many blank post-dialysis sections, while the resident stated staff did not check the port before or after dialysis. Another resident with ESRD, DM, and HTN had ordered fistula monitoring and dialysis coordination, but records lacked dialysis-related progress notes and several dialysis communication forms had no post-dialysis assessment; one later return note documented weakness, severe pain, and malaise.
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 severe cognitive impairment and Medicaid as the primary payer was transferred to the hospital for altered mental status, but the record did not show that a bed hold notice was provided to the resident or the resident’s representative. Staff gave conflicting accounts of who was responsible for giving the notice, and an LPN stated it was not provided because the transfer was an emergency.
An LPN was observed providing PEG tube meds and a dressing change for a resident without wearing the required gown for enhanced barrier protocol. The resident had severe cognitive impairment, with a BIMS score of 2, and diagnoses including traumatic brain injury and dysphagia. The LPN later stated the gown should have been worn but was forgotten.
Lint Build-Up in Dryer Mechanical Area: The facility failed to clean heavy lint accumulation from the compartment housing the gas lines and burner assemblies for 4 of 4 gas dryers. Surveyors observed all lint trap screens thickly covered with lint, and lint covering the ceiling, fire sprinkler, walls, floor, electrical conduit, wires, switches, gas lines, and air intakes/holes in the mechanical space above the dryer drums. A laundry aide stated the mechanical space had never been part of their instructions to clean, and the laundry supervisor stated the build-up was a fire hazard.
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 Provide Ordered Range of Motion Services
Penalty
Summary
The facility failed to ensure range of motion services were provided for 2 of 2 sampled residents reviewed for ROM services. Resident #8 had a BIMS score of 15, indicating cognitive intactness, and a quarterly assessment showed impairment in ROM to one side of the upper extremity and both sides of the lower extremity, with no restorative services received during the look-back period. The care plan directed nursing rehab to assist with active and passive ROM to the bilateral upper and lower extremities, but review of the electronic clinical record for August 2025 did not show ROM services were provided. The resident stated they had limited ROM in both arms and had not received ROM services in several months. Resident #7 also had a BIMS score of 15 and a quarterly assessment showing impairment in ROM on one side of the upper and lower extremities, with no restorative services received during the look-back period. The care plan identified a right-hand contracture and directed nursing rehab to provide active and passive ROM to the right upper and right lower extremities, but the electronic clinical record did not show ROM services were provided in July or August 2025. Staff interviews showed the care plan coordinator stated restorative services had been discussed but had not started because the facility had not yet hired a restorative aide, and the DON stated the facility did not have a restorative program in place, although CNAs were to complete ROM.
Incomplete Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure dialysis residents were assessed before and after dialysis for 2 of 2 sampled residents reviewed for dialysis services. For one resident with end stage renal disease and a BIMS score of 15, multiple Dialysis Communication forms showed incomplete or inaccurate pre-dialysis documentation and missing post-dialysis assessments. Several forms had pre-dialysis vital signs carried over from earlier dates, some forms showed the thrill and bruit documented even though the resident had a dialysis port to the right chest, and multiple post-dialysis sections were left blank. The resident stated the nursing staff did not check the dialysis port before or after dialysis. The ADON stated the nurse was to document the pre-dialysis assessment, send the form to the dialysis center, and document a progress note with the dialysis center’s assessment, and later stated the pre-dialysis thrill and bruit documentation was not accurate because the resident had a port and that some vital signs were automatically input from the last set of vital signs in the electronic record. For the second resident, physician orders showed the resident was dependent on renal dialysis and required monitoring of the arteriovenous fistula for signs and symptoms of trauma or infection every shift, with thrill and bruit checks every shift. Review of June, July, and August 2025 medication administration records did not show the dialysis event on the ordered schedule, and July and August progress notes did not contain dialysis-related notes or fistula assessment/monitoring documentation. By the end of the survey, progress notes showing assessment and monitoring of the fistula site were not provided. Dialysis Communication forms for this second resident showed repeated pre-dialysis assessments completed by nursing staff, but several forms had no post-dialysis assessment. One later form did include a post-dialysis note stating the resident returned with weakness, pain rated 9 out of 10 in the knees and back, and general malaise, and that dialysis vitals were not completed by dialysis. The resident’s quarterly assessment showed a BIMS of 15 and diagnoses including end stage renal disease, diabetes, and hypertension. The ADON stated the facility nurse was to document the assessment before dialysis, send the paper to the dialysis center, and document a progress note with the dialysis center’s assessment.
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 Provide Bed Hold Notification
Penalty
Summary
The facility failed to ensure that a bed hold notification was provided for Resident #36, who had Medicaid as the primary payer source, a power of attorney listed on the face sheet, and a BIMS score of 00 indicating severe cognitive impairment. The resident was sent to the hospital for altered mental status, and the nurse note for the transfer did not show that notification of the bed hold option had been provided. The resident returned to the facility several days later. During interviews, staff gave conflicting statements about who was responsible for providing the bed hold notice, including the marketer, administration, the admission coordinator, and the nursing department. An LPN stated the notice was not provided to the resident or the resident's representative because the transfer was an emergency.
Failure to Follow Enhanced Barrier Protocol During PEG Tube Care
Penalty
Summary
The facility failed to ensure infection control measures were implemented during PEG tube care for one resident. On 08/28/25 at 1:29 p.m., an LPN was observed administering PEG tube medications and performing a PEG tube dressing change for Resident #34 without donning the appropriate personal protective equipment, specifically a gown, required for enhanced barrier protocol. Resident #34 had a quarterly assessment dated 07/21/25 showing a BIMS score of 2, indicating severe impairment in daily decision making, and diagnoses that included traumatic brain injury and dysphagia. During interview on 08/28/25 at 1:57 p.m., the LPN stated they should have followed enhanced barrier protocol but had forgotten to put on the gown.
Lint Build-Up in Dryer Mechanical Area
Penalty
Summary
The facility failed to clean lint build-up from the compartment that housed the gas lines and burner assemblies for 4 of 4 gas dryers in the laundry room. During observation, all four lint trap screens under the dryer drums were found thickly covered with lint, and the space behind the dryers had lint covering the ceiling, fire sprinkler, mechanical space above the dryer drums, floor, walls, electrical conduit, wires, switches, gas lines, and the air intakes/holes for the gas dryer burner tube assembly. Pictures were taken of these conditions. Laundry Aide #1 stated the lint screens were cleaned once daily and the space behind the dryers was swept about once a week, and also stated they were usually assigned to sweep behind the dryers but had never been instructed to clean the mechanical space above the dryer drums. The laundry supervisor stated laundry aides were to clean the lint traps multiple times a day and that the area behind the dryers was usually swept about once a week. After reviewing the pictures, the laundry supervisor stated they did not realize there was so much lint build-up on the ceiling, sprinkler, and walls, and stated the lint build-up in the mechanical area above each of the four dryers was a fire hazard.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 94 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jenks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Village Retirement Community | 0.9 mi | ★★★★★ | 0 | 0 |
| Zarrow Pointe | 2.4 mi | ★★★★★ | 2 | 0 |
| Ambassador Manor Nursing Center | 3.2 mi | ★★★★★ | 4 | 0 |
| The Villages At Southern Hills | 3.5 mi | ★★★★★ | 0 | 0 |
| Montereau, Inc. | 4 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.