Gracewood Health & Rehab

In the surveyor’s words

From the most serious findings on record at Gracewood Health & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 6, 2026

  Based on record review and interview, the facility failed to ensure a resident was not physically abused by another resident for 1 (#79) of 4 sampled residents reviewed for abuse.The administrator identified 69 residents resided in the facility.A Resident to Resident Incidents policy, dated 01/2024, read in part, Upon admission to the facility, each person will be assessed through the MDS process to determine if they are at risk for abusing others.Care plans will address interventions designed to prevent occurrences.An Oklahoma State Department of Health final report, dated 05/11/25, showed a staff member witnessed Resident #79 pour water on Resident #61. Resident #61 then pushed Resident #79 causing them to fall. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2026

  Based on observation, record review, and interview, the facility failed to ensure: a. food items were properly sealed, dated, and labeled; b. bulging containers were removed from circulation in the dry storage; c. ensure food preparation utensils were stored in a clean environment; and d. ensure areas near food preparation were clean and free from pests, including a microwave for resident use.The administrator identified 69 residents ate meals from the kitchen.Findings: On 03/31/26 at 10:15 a.m., kitchen utensils were observed to hang over the sink where dirty dishes were to be washed.On 03/31/26 at 10:18 a.m., the following items were observed in the refrigerator:A bag of square brown patties was observed with no label or date,a pitcher of orange liquid was observed with no label or date,… […]

• No harm, potential for more than minimal, widespreadF839Oct 3, 2024

  Based on observation, record review, and interview, the facility failed to ensure staff was licensed in accordance with applicable State laws. The DON identified 78 residents who resided in the facility. Findings: On [DATE] at 12:45 p.m., RN #1 was observed at the nurse station. They stated they were working as the charge nurse for the shift. An employee record documented RN #1 had a valid RN license for the state of Texas. There was no record for a valid RN license for the state of Oklahoma. On [DATE] at 10:50 a.m., the administrator reviewed RN #1's employee file noting a Texas RN license. […]

• No harm, potential for more than minimal, patternF584Apr 6, 2026

  Based on observation and interview the facility failed to:a. ensure a safe and sanitary kitchen floor, b. residents were not served meals on paper products, andc. ensure hot water was available in their restroom for 1 (#21) of 17 sampled residents reviewed for access to hot water in their restroom. The administrator identified 69 residents ate from the kitchen. Findings: On 03/31/26 at 10:18 a.m., the tile floor between the two sinks on opposite sides of the kitchen was observed to have been ripped up and was filled in with gravel. On 03/31/26 at 11:01 a.m., [NAME] #2 stated All I can do is wipe down and sanitize as much as I can. […]

• No harm, potential for more than minimal, patternF583Jan 14, 2025

  Based on observation, record review, and interview, the facility failed to ensure residents were provided with privacy curtains. The administrator identified 78 residents resided at the facility. Findings: A Bedrooms policy, reviewed May 2024, read in part, Each room is designed to provide full visual privacy for each resident (in the form of ceiling suspended curtains that extend around the bed) and equipped for adequate nursing care On 01/06/25 at 4:26 p.m., room [ROOM NUMBER] was observed to have no privacy curtain. Resident #24 stated there was no privacy and all activities other than using the restroom were completed in full view of their roommate. On 01/07/25 at 11:52 a.m., room [ROOM NUMBER] was observed to have no privacy curtain. The room had two residents residing in the room. […]