Accel at Crystal Park: PEG Tube Medication Failure - OK
The patient was Resident #1, a stroke survivor who cannot speak. She has an unstageable pressure ulcer at the base of her spine.
The incident happened on the morning of May 27, 2026, at Accel at Crystal Park, a nursing facility on SW 80th Street in Oklahoma City. An inspector was present and watched the entire sequence unfold.
LPN #2 entered the room at 9:25 a.m., stopped the tube feeding, and checked for placement and residual. So far, correct. Then she poured water and crushed medication into a 30 ml cup and held the PEG tube open, attempting to pour the diluted mixture straight in. The liquid spilled out over and around the tube. She got a second cup of medication. She picked up a syringe. Then she stopped, because she did not know how to connect the syringe to the tube.
She activated the call light and said she would need help.
The Director of Nursing arrived at 9:48 a.m. and stood in the room providing instruction on how to administer medication through a PEG tube.
At 10:20 a.m., LPN #2 told the inspector she was unsure how much medication Resident #1 had actually received when the first cup spilled. The DON confirmed the medication had spilled and the resident did not get her full dose. The DON also said LPN #2 should have notified the physician. There is no indication in the inspection report that the physician was contacted.
What made this worse was what the DON said the next morning.
On May 28, the DON told the inspector that LPN #2 had never completed a skills competency checklist. The facility gives nurses 90 days after hire to complete it. LPN #2 was past that window. The DON said the facility had no formal policy to track whether those checklists were ever finished.
The facility's own medication administration policy, dated May 2023, states that in-service training on the safe administration of medications through enteral tubes is provided to nursing personnel. The DON told inspectors that nurses are supposed to complete competency checklists when hired and annually at a skills fair. LPN #2 had done neither.
A physician's order in the resident's chart, dated October 2025, was specific: flush the PEG tube with 30 ml of water before and after medications, and use 15 ml of water between each medication. That order existed. The competency to carry it out did not.
Resident #1 cannot report what she experienced. Aphasia, a condition that commonly follows stroke, has left her without the ability to speak. She has a wound that inspectors described as unstageable, meaning tissue damage so deep its severity cannot be fully assessed. She depends on a feeding tube for nutrition and medication. She depends on the nurses assigned to her to know what they are doing.
On the morning of May 27, the nurse assigned to her did not.
The inspection was conducted in response to a complaint. Inspectors cited the facility for failing to ensure licensed nurses had the competency skills necessary to administer medication via PEG tube. The deficiency was tagged at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. Whether Resident #1 suffered any consequence from missing an unknown portion of her medication that morning is not documented in the inspection report.
The DON acknowledged, at the end of the two-day inspection, that a process was needed to make sure competency checklists were actually completed. That process did not exist on the morning a nurse stood at a stroke patient's bedside, medication spilling, and reached for the call light.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At Crystal Park from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
Accel At Crystal Park in Oklahoma City, OK was cited for violations during a health inspection on May 28, 2026.
The patient was Resident #1, a stroke survivor who cannot speak.
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.