Grace Skilled Nursing And Therapy Jenks

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation and interview the facility failed to ensure a clean comfortable homelike environment for 1 (#4) of 3 sampled residents reviewed for environment.The administrator identified 100 residents resided in the facility. Findings: On 11/05/25 at 9:05 a.m., Resident #4's room was observed. Two slats on

the mini blinds were broken off and were missing. A one foot by one foot area on the North wall was missing paint, and several other smaller areas along the North and East wall were observed to be missing paint.On 11/05/25 at 9:05 a.m., Resident #4 stated the blinds had been broken and the paint had been missing for the three years they had been at the facility.On 11/05/25 at 9:15 a.m., CNA #1 stated they were new and they were unsure who was responsible for painting the rooms and replacing the blinds.On 11/05/25 at 9:20 a.m., LPN #2 stated that maintenance was responsible for the blinds and paint. LPN #2 stated they were unaware if maintenance was aware of the condition of Resident #4's room.On 11/05/25 at 9:25 a.m., the maintenance supervisor stated they were responsible for repainting resident rooms and replacing broken mini blinds.On 11/06/25 at 10:55 a.m., the administrator stated issues with the rooms should be reported to maintenance so they can be addressed.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Skilled Nursing and Therapy Jenks

711 North 5th Street Jenks, OK 74037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692

Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview, the facility failed to ensure nutritional supplements were provided as ordered for 1 (#2) of 3 sampled residents reviewed for nutrition. The DON identified 48 residents were ordered supplements.Findings:A weight entry, dated 09/11/25, showed Resident #2 weighed 130.8 pounds.An annual assessment, dated 09/12/25, showed Resident #2 had a BIMS score of 00, which indicated the resident was severely impaired in cognition for daily decision making, had a diagnosis of dementia, and had a feeding tube.A care plan, updated 09/25/25, showed Resident #2 had a potential nutritional problem and was at risk for weight fluctuations.A nutrition note, dated 09/26/25, showed a recommendation from the dietician for 2.0 cal (a nutritional supplement) 30cc twice daily via feeding tube.A nurse note, dated 10/01/25, showed the facility had received a new order for 2.0 cal 30cc twice daily via feeding tube. The note was signed by the ADON. A physician order, dated 10/01/25, showed Resident #2 had been ordered 2.0 cal 30cc twice daily via feeding tube twice daily.A weight entry, dated 10/14/25, showed Resident #2 weighed 131.6 pounds.Review of the medication/treatment administration record, dated 10/01/25 through 10/31/25, did not show the order for 2.0 cal 30cc twice daily via feeding tube.Review of the medication/treatment administration record, dated 11/01/25 through 11/03/25, did not show the order for 2.0 cal 30cc twice daily via feeding tube.On 11/05/25 at 10:18 a.m., LPN #1 reviewed the medication/treatment record for Resident #2 and stated the only supplements they were ordered and received vitamin C, zinc, and a multivitamin. LPN #1 stated they or an ACMA were responsible to administer supplements via feeding tube to Resident #2.On 11/05/25 at 10:22 a.m., ACMA #1 reviewed the medication/treatment record for Resident #2 and stated they were currently ordered supplements to include vitamin C, iron, zinc, and a multivitamin.On 11/05/25 at 11:32 a.m., the ADON stated when the order was entered into the electronic clinical record for the 2.0 cal nutritional supplement it had not carried over onto

the medication/treatment record for administration.On 11/05/25 at 3:50 p.m., the DON stated the order for 2.0 cal had not been placed on the medication/treatment record for administration for Resident #2. They stated they audited new orders daily, but they had not identified the nutritional supplement had not been placed on the medication/treatment record for administration by the charge nurse or the ACMA.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Skilled Nursing and Therapy Jenks

711 North 5th Street Jenks, OK 74037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

A significant change assessment, dated 09/13/25, showed Resident #5 had a BIMS score of 4 which was indicative of severe cognitive impairment.

A physician's order, dated 10/12/25, showed to cleanse the stage 3 pressure ulcer to Resident #5's sacrum with normal saline, pat dry, apply Triad (wound dressing) and cover with bordered foam every Tuesday, Thursday and Saturday.

Review of the treatment administration record from 10/12/25 through 11/01/25 did not show documentation wound care had been completed on 10/18/25, 10/25/25 or 11/01/25.

On 11/06/25 at 8:30 a.m., wound care nurse #2 stated they had performed the wound care for Resident #5

on 11/01/25, but they had not documented it.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet