Grace Skilled Nursing Jenks: Records Violations - OK
The resident, identified only as Resident #2 in inspection documents, weighed 130.8 pounds on September 11. Assessment records from the next day showed the person had severe cognitive impairment with a BIMS score of 00 — the lowest possible rating for daily decision-making ability — and required all nutrition through a feeding tube.
By late September, the facility's dietician recommended nutritional supplements. A nutrition note dated September 26 called for "2.0 cal 30cc twice daily via feeding tube" — a high-calorie supplement designed to prevent further weight loss.
The physician's order came through on October 1. An assistant director of nursing signed a nurse note that day confirming the facility had received the new order for the twice-daily supplements through the feeding tube.
But the supplements never reached the patient.
When federal inspectors reviewed medication administration records from October 1 through October 31, no entry existed for the nutritional supplement order. Records from November 1 through November 3 also showed no sign of the supplements being given.
Instead, the resident received only basic vitamins. On November 5, LPN #1 told inspectors that Resident #2 was getting "vitamin C, zinc, and a multivitamin" — nothing about the calorie-dense supplement the doctor had ordered more than a month earlier.
ACMA #1, an advanced certified medication aide, confirmed the same limited vitamin regimen when questioned that morning. The aide mentioned "vitamin C, iron, zinc, and a multivitamin" but made no reference to the 2.0 cal supplement.
The assistant director of nursing admitted the breakdown when confronted by inspectors at 11:32 a.m. on November 5. The order had been "entered into the electronic clinical record" but "had not carried over onto the medication/treatment record for administration."
In nursing homes, that transfer step is crucial. Physicians' orders mean nothing if they don't reach the medication administration records that staff use for daily care. Without the order appearing on those records, no nurse or aide would know to give the supplements.
The director of nursing acknowledged the system failure that afternoon. The 2.0 cal order "had not been placed on the medication/treatment record for administration," despite the facility's policy of daily audits for new orders.
Those audits had failed completely. Neither the charge nurse nor the medication aide had caught the missing supplement order during their daily reviews. For 35 days, a cognitively impaired resident who relied entirely on tube feeding went without the nutritional support a dietician and physician had deemed necessary.
The resident's care plan, updated on September 25, had specifically identified "potential nutritional problem" and risk for "weight fluctuations." By October 14, the person weighed 131.6 pounds — a modest gain of less than one pound over the previous month.
But that minimal weight gain came without the benefit of the prescribed supplements. The resident's nutrition depended entirely on whatever base formula was being delivered through the feeding tube, while the calorie-dense supplement that might have supported better weight gain sat unused.
The facility told inspectors that 48 residents were currently ordered nutritional supplements. If the same system breakdown affected other residents, dozens of people could be missing prescribed nutrition support.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm." But for Resident #2, the consequences were immediate: more than a month without medically recommended nutrition support during a period when maintaining weight was already identified as a clinical challenge.
The breakdown revealed a fundamental failure in the facility's medication management system. Physician orders that never reach the people responsible for daily care become meaningless pieces of paper, leaving vulnerable residents without the medical interventions their doctors prescribed.
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 resident, identified only as Resident #2 in inspection documents, weighed 130.8 pounds on September 11.
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.