Grace Skilled Nursing Jenks: Nutrition Failures - OK
The resident, identified only as Resident #2, weighed 130.8 pounds on September 11 and had severe cognitive impairment with a BIMS score of 00, indicating complete inability to make daily decisions. The patient required all nutrition through a feeding tube.
On September 26, the facility's dietician recommended 2.0 cal nutritional supplements — 30cc twice daily via feeding tube — noting the resident had potential nutritional problems and was at risk for weight fluctuations.
The physician formally ordered the supplements on October 1. The assistant director of nursing signed off on receiving the new order that same day.
But the supplements never made it to the patient.
When inspectors reviewed medication administration records from October 1 through October 31, they found no trace of the 2.0 cal supplement order. The November records showed the same gap — vitamins and minerals, but no nutritional supplement.
On November 5, Licensed Practical Nurse #1 reviewed the patient's medication record and confirmed the resident was only receiving vitamin C, zinc, and a multivitamin. The LPN explained that either they or an ACMA — assistant certified medication aide — would be responsible for administering supplements through the feeding tube.
Minutes later, ACMA #1 reviewed the same records and listed the current supplements: vitamin C, iron, zinc, and a multivitamin. No mention of the 2.0 cal supplement ordered five weeks earlier.
The assistant director of nursing admitted the problem at 11:32 that morning. When the order was entered into the electronic clinical record, it "had not carried over onto the medication/treatment record for administration."
The director of nursing acknowledged the failure that afternoon. The 2.0 cal order "had not been placed on the medication/treatment record for administration." Despite daily audits of new orders, supervisors had not identified that the nutritional supplement was missing from the administration records.
The patient's weight had increased slightly to 131.6 pounds by October 14, but inspectors found the facility had failed to provide the ordered nutritional support for over a month.
The breakdown occurred at multiple levels. The dietician made the recommendation. The physician wrote the order. The assistant director of nursing received and signed off on the order. But the critical step — getting the supplement onto the daily medication administration record — never happened.
The facility's own care plan, updated September 25, had identified the resident as having a "potential nutritional problem" and being "at risk for weight fluctuations." Yet when the dietician and physician responded with specific nutritional intervention, the system failed to deliver it.
For a patient entirely dependent on tube feeding, missing ordered nutritional supplements means missing essential calories and nutrients that cannot be obtained any other way. The resident had no ability to request the missing supplements or even understand they were supposed to receive them.
The director of nursing told inspectors that 48 residents at the facility were ordered supplements, suggesting the medication administration process handles dozens of such orders regularly. But the daily audit system designed to catch missing orders had failed to identify this gap for more than five weeks.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The facility's failure affected what inspectors described as "few" residents, though the inspection focused on this single case where a vulnerable patient with severe dementia went without ordered nutritional support while staff administered vitamins but missed the supplement their doctor had specifically prescribed.
The case illustrates how administrative failures in nursing homes can leave the most vulnerable residents — those with severe cognitive impairment who depend entirely on staff for basic nutrition — without the medical care their physicians have ordered.
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 2025-11-21 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 November 21, 2025.
The patient required all nutrition through a feeding tube.
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.