The Grand at Bethany: Stage III Pressure Ulcer - OK
The resident at The Grand at Bethany Skilled Nursing and Therapy developed a stage III pressure ulcer that measured 6 centimeters by 11 centimeters, according to a federal inspection completed in August following a complaint.
Resident #1 was admitted December 17, 2024, with a history of cardiac arrest that caused brain damage, congestive heart failure, kidney injury, and required a feeding tube. The patient needed total care and had significant swelling throughout their body.
A skin assessment on the day of admission found redness and superficial breakdown on the tailbone area. Staff ordered cleaning with saline solution and applying Triad cream twice daily for wound prevention.
Five days later, the breakdown had worsened to "shearing to sacrum." A December 22 assessment noted a pillow was placed under one side to relieve pressure, and the resident's family member confirmed they understood the treatment plan.
The situation deteriorated further. By December 23, wound care specialists documented a stage III pressure injury — a deep wound that extends through the skin into fat tissue. The ulcer showed serosanguineous drainage and remained unhealed.
During an August telephone interview, the family member told inspectors the wound "initially looked like a scratch from square fingernails" but developed while their loved one was a resident at the facility.
The family member said the resident "was not receiving enough water and was not turned and repositioned as needed." They described having to actively search for nursing staff during visits. "When family visited, they would have to go find nurses to turn Resident #1," the inspection report states.
The facility's director of nursing acknowledged during the inspection that "Resident #1 was not skilled appropriately due to being total care with lots of edema." The administrator said the facility had addressed the family's concerns.
The nursing director also questioned the accuracy of earlier documentation, telling inspectors "the nurse who documented the shearing may not have been as accurate as the wound care person when staging pressure wounds."
Stage III pressure ulcers represent serious medical complications that develop when patients remain in the same position too long without adequate repositioning. The wounds extend through multiple layers of skin and can take months to heal, if they heal at all.
Federal regulations require nursing homes to provide care and services to prevent pressure ulcers from developing or worsening. Facilities must ensure residents receive adequate nutrition, hydration, and repositioning to maintain skin integrity.
The inspection found the facility failed to meet these standards for this resident, who required total care due to their medical conditions and physical limitations from brain damage.
The Grand at Bethany houses 103 residents. Inspectors reviewed three residents' pressure ulcer care as part of their investigation and found deficient care in one case.
The family member's account suggests systemic staffing problems that prevented adequate patient monitoring and care. Their need to locate nurses during visits to ensure their loved one received basic repositioning care indicates potential understaffing or inadequate care protocols.
The progression from superficial skin breakdown on admission to a deep stage III pressure ulcer within six days suggests the facility's prevention measures failed despite documented treatment orders and family involvement.
The resident's multiple serious medical conditions, including brain damage from cardiac arrest and significant body swelling, made them particularly vulnerable to skin breakdown. Such patients require frequent repositioning, careful skin monitoring, and adequate hydration to prevent pressure injuries.
The facility received a citation for failing to provide appropriate pressure ulcer care and prevent new ulcers from developing. Inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
The case illustrates how quickly skin conditions can deteriorate in vulnerable nursing home residents when prevention protocols aren't properly implemented or when staffing levels prevent adequate patient monitoring and care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Grand At Bethany Skilled Nursing and Therapy from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for The Grand At Bethany Skilled Nursing and Therapy
- Browse all OK nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
THE GRAND AT BETHANY SKILLED NURSING AND THERAPY in BETHANY, OK was cited for violations during a health inspection on August 19, 2025.
The patient needed total care and had significant swelling throughout their body.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at THE GRAND AT BETHANY SKILLED NURSING AND THERAPY?
- The patient needed total care and had significant swelling throughout their body.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in BETHANY, OK, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from THE GRAND AT BETHANY SKILLED NURSING AND THERAPY or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 375107.
- Has this facility had violations before?
- To check THE GRAND AT BETHANY SKILLED NURSING AND THERAPY's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.