Grace Skilled Nursing Jenks: Safety Violations - OK
The resident, identified only as Resident #2 in inspection records, weighed 130.8 pounds in September and had a feeding tube due to severe dementia. Annual assessments showed the person scored zero on cognitive evaluations, indicating complete impairment in daily decision-making.
On September 26, the facility's dietician recommended 2.0 cal nutritional supplements, 30cc twice daily via feeding tube. The assistant director of nursing signed a note on October 1 confirming receipt of the new physician order for the same supplement regimen.
The physician formally ordered the supplements on October 1. The resident's weight had increased slightly to 131.6 pounds by October 14.
But the supplements never made it to the patient.
Medication administration records from October 1 through October 31 show no entry for the ordered 2.0 cal supplements. Records from November 1 through November 3 also lack any documentation of the nutritional supplements.
When inspectors arrived November 5, they discovered the gap immediately. LPN #1 reviewed the medication records at 10:18 a.m. and confirmed the resident received only vitamin C, zinc, and a multivitamin. The nurse said either they or a certified medication aide were responsible for administering supplements through feeding tubes.
Twenty minutes later, a certified medication aide reviewed the same records and listed the resident's supplements as vitamin C, iron, zinc, and a multivitamin. No mention of the 2.0 cal supplement ordered five weeks earlier.
The assistant director of nursing acknowledged the system failure at 11:32 a.m. She explained that when the supplement order was entered into the electronic clinical record, "it had not carried over onto the medication/treatment record for administration."
The director of nursing confirmed the breakdown at 3:50 p.m. The 2.0 cal supplement order "had not been placed on the medication/treatment record for administration." She said she audited new orders daily but had not identified that the nutritional supplement was missing from administration records.
The facility cares for 48 residents who require nutritional supplements, according to the director of nursing. The inspection focused on three residents' nutritional care.
Federal regulations require nursing homes to provide adequate nutrition and hydration to maintain residents' health. Nutritional supplements become critical for residents with feeding tubes, particularly those with dementia who cannot communicate hunger or nutritional needs.
The resident's care plan, updated September 25, specifically identified a "potential nutritional problem" and noted the person was "at risk for weight fluctuations." Despite this documented risk and the dietician's recommendation, the ordered supplements never reached the patient.
The breakdown occurred at multiple levels. The physician wrote the order. The assistant director of nursing documented receiving it. The director of nursing conducted daily audits of new orders. Yet the supplement disappeared between the electronic clinical record and the medication administration system where nurses track what patients actually receive.
Neither the licensed practical nurse nor the certified medication aide who administered the resident's other supplements knew about the 2.0 cal order. Both described their responsibilities for feeding tube administration but had no record of the nutritional supplement in their daily medication lists.
The resident with severe dementia and a feeding tube went 34 days without the twice-daily nutritional supplements their physician ordered and their dietician recommended. The facility's daily auditing system, designed to catch such gaps, failed to identify the missing supplement until federal inspectors arrived.
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 records, weighed 130.8 pounds in September and had a feeding tube due to severe dementia.
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.