Grace Skilled Nursing: Fall Mat Missing During Injury - OK
The August incident at Grace Skilled Nursing and Therapy Jenks involved Resident #48, who had an extensive fall prevention plan that included keeping a fall mat at bedside along with other interventions. When the resident fell, they hit their head and scraped both knees, requiring hospitalization for evaluation and treatment.
The resident's care plan, revised on August 12, outlined multiple fall prevention strategies. Staff were supposed to ensure a baby doll stayed in bed with the resident, assist with nighttime toileting, use a concave mattress, educate about not removing oxygen equipment, maintain the fall mat at bedside, post signs asking for help, keep the call light within reach, keep the bed in its lowest position, and provide nonskid footwear before transfers.
Yet when inspectors asked staff about the interventions just days after the fall, the responses revealed significant gaps in implementation.
On September 2, CNA #1 could only identify two interventions for Resident #48: the fall mat and keeping the bed low. The next day, CNA #4 gave the same limited response, acknowledging they "did not know why the fall mat was not there" when the resident fell.
The Director of Nursing told inspectors on September 3 that they had provided in-service training and education to staff and observed to ensure interventions were in place. But the fall itself suggested these oversight efforts had failed.
LPN #4, who was involved in responding to the incident, provided conflicting accounts when questioned by inspectors. Initially, they stated Resident #48 was "observed partially on the fall mat when they fell." But their uncertainty about basic details of the incident raised questions about the accuracy of this account.
"The event was so rushed they were trying to remember," the LPN explained to inspectors about their recollection.
The nurse couldn't determine what the resident had struck when falling. "They were not sure if Resident #48 hit their head on the nightstand, bed side table, or a clothes hamper that was close to them," according to the inspection report. The LPN noted they "did not see blood on anything, so they were not sure."
Despite this uncertainty about the fall's details, LPN #4 insisted to inspectors that the resident "had the fall mat because they used it anytime Resident #48 was in bed."
This assertion directly contradicted what other staff members told inspectors about the mat's absence during the fall.
The nursing note documenting the incident showed the resident complained of generalized pain following the fall. Neurological checks were initiated as a precaution given the head injury. A physician's order was received to send the resident to the hospital for evaluation and treatment of their injuries.
The case illustrates how detailed care plans can fail when staff don't consistently implement basic safety measures. Resident #48's plan included nine specific interventions designed to prevent falls, yet the most fundamental one - placing a mat beside the bed to cushion any fall - wasn't in place when needed.
The facility's own documentation showed staff understood the importance of fall mats for this particular resident. The August care plan revision specifically listed the bedside fall mat as a required intervention. Multiple staff members identified it as one of the resident's key safety measures when questioned by inspectors.
Yet when the resident actually fell, sustaining injuries that required hospitalization, the mat wasn't there.
The incident occurred despite what the Director of Nursing described as active staff education and observation to ensure interventions were properly implemented. The gap between policy and practice left a vulnerable resident without a basic safety protection at the moment they needed it most.
Federal inspectors classified the violation as causing minimal harm with few residents affected, but for Resident #48, the consequences were immediate and painful. The fall resulted in visible injuries and a hospital trip that might have been prevented if staff had consistently followed the established care plan.
The resident's injuries - abrasions to the forehead and both knees - served as physical evidence of what happens when fall prevention protocols break down at the bedside level.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grace Skilled Nursing and Therapy Jenks from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
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 20, 2026 · Our methodology
Grace Skilled Nursing and Therapy Jenks in Jenks, OK was cited for violations during a health inspection on September 3, 2025.
When the resident fell, they hit their head and scraped both knees, requiring hospitalization for evaluation and treatment.
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.