The Grand at Bethany: Pressure Ulcer Failures - OK
A federal complaint inspection at The Grand at Bethany Skilled Nursing and Therapy, completed August 19, 2025, found the facility failed to prevent a pressure ulcer from developing and worsening in a resident who arrived already at serious risk. The facility housed 103 residents at the time.
Resident #1 was admitted December 17, 2024, with a history of cardiac arrest that had caused anoxic brain damage, congestive heart failure, acute kidney injury, acute respiratory failure, and dependence on a feeding tube. A skin assessment completed the day of admission noted redness and superficial breakdown at the sacrum. Staff ordered a topical cream applied twice daily and instructed nurses to cleanse the area with saline for 14 days.
Five days later, on December 22, the assessment documented shearing at the sacrum. The note recorded that a pillow had been placed under one side to offload pressure, and that the resident's family member had confirmed understanding of the wound management plan.
One day after that, a wound care note dated December 23 told a different story. The wound had been formally staged as a Stage III pressure injury, meaning it had broken through the skin and into the underlying tissue. It measured 6 centimeters by 11 centimeters, with a depth of 0.2 centimeters. The note documented serosanguineous drainage and called for a bordered foam dressing in addition to the cream.
The family, interviewed by phone on August 18, 2025, said the wound started as something that looked minor. What they described next was the more troubling part. Resident #1 was not receiving enough water, they said. The resident was not being turned and repositioned as needed. When family came to visit, they had to go find nurses themselves to come turn their loved one.
For a resident who was total care, dependent on a feeding tube, and dealing with significant edema, turning and repositioning is among the most basic defenses against pressure wounds. The skin breaks down when the same surface bears weight for too long. A resident who cannot move independently relies entirely on staff to shift that weight.
The Director of Nursing, interviewed the same afternoon at 4:03 p.m., said Resident #1 had not been "skilled appropriately" because of being total care with significant edema. The DON said the family's concerns had been addressed. She also said the nurse who documented shearing on December 22 may not have been as accurate as the wound care specialist when it came to staging pressure wounds.
That explanation raised its own question. The December 22 note described shearing and documented an active wound management plan. Whether the nurse staged the wound correctly or not, the documentation showed staff knew something was happening at the sacrum. By the next day, the wound care specialist confirmed it had become a Stage III injury.
Federal inspectors cited the facility for failing to ensure the resident received care and services to prevent pressure ulcers from developing or worsening. The harm level was classified as minimal, with few residents affected.
The family's account, that they were the ones tracking down nurses to perform repositioning, was not contradicted in the inspection findings. The DON said the concerns had been addressed. She did not say they were unfounded.
Resident #1 arrived at The Grand at Bethany already fragile, already compromised, already relying on staff for every basic function. The family watched a scratch become a wound that inspectors were still documenting eight months later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Grand At Bethany Skilled Nursing and Therapy from 2025-08-19 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
THE GRAND AT BETHANY SKILLED NURSING AND THERAPY in BETHANY, OK was cited for violations during a health inspection on August 19, 2025.
The facility housed 103 residents at the time.
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.