Grace Skilled Nursing and Therapy Jenks

Based on observation and interview, the facility failed to clean the lint build-up from the compartment which housed the gas lines and burner assemblies for 4 of 4 gas dryers in the laundry room. The administrator identified 107 residents resided in the facility. Findings:On 09/03/25 at 11:05 a.m., Laundry aide #1 assisted with the observations of the four gas dryers in the laundry room. Laundry Aide #1 pulled open each of the lint trap doors housed under each dryer drum. All four lint trap screens were thickly covered with lint. The space behind the dryers was observed to have lint covering the ceiling, the fire sprinkler, and the mechanical space above each of the four dryer drums. The mechanical space above the dryer drums housed the gas lines and dryer burner tube assembly. The lint covered the ceiling, floor, walls, electrical conduit, wires, switches, gas lines, and air intakes/holes for the gas dryer burner tube assembly of the mechanical space. Pictures were taken of the observations described above. On 09/03/25 at 11:10 a.m., Laundry aide #1 stated they cleaned the lint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure resident's right of choice regarding diet for 1 (#2) of 3 residents sampled reviewed for resident rights. The administrator identified 111 residents resided at the facility. Findings: On 05/28/25 at 8:23 a.m., Resident #2 was observed to be in their room drinking soda. An admission assessment, dated 07/25/23, showed Resident #2 had a brief interview for mental status score of 14 which indicated the resident's cognition was intact. The assessment showed the resident had diagnoses which included history of stroke and aphasia. A physician's order, dated 07/25/23, showed a regular diet of regular texture and thin liquids. A hospital discharge record, dated 01/11/24, showed a diet order for low cholesterol, low fat, and low sodium. A physician's order, dated 01/11/24, showed a regular diet, level 6-soft and bite-sized texture with honey thick liquids. On 05/28/25 at 8:23 a.m., Resident #2 stated they received a soft diet and did not want a soft diet and thickened liquids. They stated they had not ever…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure chemicals were secured for three (100/200 hall, 700 hall, and 800 hall) of eight halls observed. The facility map identified eight halls in the facility. Findings: The Housekeeping policy, dated 06/29/12, read in part, .ALL HARMFUL CHEMICALS .MUST BE STORED IN A LOCKED STORAGE AT ALL TIMES, BEFORE AND AFTER USE . The Red Juice Stain Remover MSDS, dated 03/25/15, read in part, .KEEP OUT OF REACH OF CHILDREN . The Film Away MSDS, dated 04/16/15, read in parts, .Store locked up . The Shineline Emulsifier Plus MSDS, read in part, .Keep out of reach of children . The PRO-543 Universal Wallcovering Adhesive MSDS, dated 08/09/18, read in part, .Keep out of the reach of children . The FiberPRO TLC MSDS, dated 10/07/21, read in part, .Causes severe skin burns and eye damage .Store locked up . The [NAME] Clean + Protect or Advanced Clean + Protect MSDS, dated 06/20/23, read in part, .Store Out Of Reach Of Children . The Xcelente MSDS, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure food items were labeled and dated. The DON identified 122 residents received nourishment from the kitchen. Findings: On 09/16/24 at 8:50 a.m., two plastic containers with sliced cheese, one plastic container with diced onion, one plastic container with diced tomatoes, one plastic container with diced honey dew melon, one paper plate with sliced cheese, and one opened container of tuna salad were observed in refrigerator #1. The food products were not labled and dated. On 09/16/24 at 8:55 a.m., dietary manager #1 stated they do not know why the containers were not labeled or dated, but they should be.

Based on record review, and interview, the facility failed to ensure a resident who had not had a bowel movement for three more days had their attending physician notified for one (#16) of one sampled resident reviewed for constipation. The DON identified 70 residents who had a diagnosis of constipation. Findings: The facility policy, titled Nursing Policies and Procedures Constipation, dated 10/10/03, read in part, .It is the policy of the facility to identify bowel elimination problems and intervene to assist residents with optimal bowel elimination. Assessment for constipation is initiated from a resident complaint or observation that the resident has been 3 days without a bowel movement .procedure for identification .review the flow sheet documentation to determine frequency .assess for signs and symptoms of constipation .identify usual bowel elimination patterns .procedure for correction notify the attending physician . Resident #16 had diagnoses which included encounter for orthopedic aftercare following a surgical ambulation and constipation. Resident #16's quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined the facility failed to report an allegation of neglect to OSDH for one (#86) of one sampled resident reviewed for neglect. The DON identified 123 residents resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy, revised 12/28/17, read in part, .neglect is defined as failure to provide good and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas .Facility responsibility .All allegations and incidents of abuse, neglect .must be reported to appropriate Federal and State Agencies including OSDH and investigated . Resident #86's quarterly MDS assessment, dated 07/18/24 , documented their cognition was intact and they had no cognitive impairments. The facility form, Quality Assurance Patient Concern Form, dated 09/10/24, read in part, .Resident complained about nurse aide not providing good care. Nurse Aide was told to help change people but refused . There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined the facility failed to thoroughly investigate an allegation of neglect for one (#86) of one sampled resident reviewed for neglect. The DON identified 123 residents resided in the facility. Findings: The Resident Abuse, Neglect and Misappropriation of Property policy, revised 12/28/17, read in part, .neglect is defined as failure to provide good and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas .Facility responsibility .All allegations and incidents of abuse, neglect .must be .investigated . Resident #86's quarterly MDS assessment, dated 07/18/24 , documented their cognition was intact and they had no cognitive impairments. The facility form, Quality Assurance Patient Concern Form, dated 09/10/24, read in part, .Resident complained about nurse aide not providing good care. Nurse Aide was told to help change people but refused . There was no documentation the facility completed a thorough investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure assessments were transmitted within the time frame for one (#53) of one sampled resident who was reviewed for timely transmission of assessments. The DON identified 123 residents who resided in the facility. Findings: Resident #53 had diagnoses which included dementia. The electronic clinical record documented a significant change assessment had an ARD date of 06/20/24 and was completed 07/04/24. A Assessment History form, dated 09/20/24, documented the significant change assessment, dated 06/20/24, had been transmitted on 09/16/24. On 09/20/24 at 1:23 p.m., corporate MDS coordinator #1 stated during the time of the transmission of the significant change assessment the facility had not had an MDS coordinator. They stated they had been assisting with MDS completion and transmission. On 09/20/24 at 1:34 p.m., corporate MDS coordinator #1 stated the facility's MDS coordinator and the corporate office were responsible to monitor to ensure assessments were transmitted timely. They stated monitoring occurred twice a week…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure a resident who had not had a bowel movement for three more days had their attending physician notified for one (#16) of one sampled resident reviewed for hospitalization. Resident #16 had not had a bowel movement for five days and was not assessed for the constipation. Resident #16 was sent to the hospital in pain with and admitted for stercoral colitis (a condition caused by constipation). The DON identified 70 residents who had an active diagnosis of constipation. Findings: The facility policy titled Nursing Policies and Procedures Constipation, dated 10/10/03, read in part, .It is the policy of the facility to identify bowel elimination problems and intervene to assist residents with optimal bowel elimination. Assessment for constipation is initiated from a resident complaint or observation that the resident has been 3 days without a bowel movement .procedure for identification .review the flow sheet documentation to determine frequency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to keep medication records in order and keep an accurate account of reconciled controlled drugs for one (Resident #110) of one sampled resident reviewed for drug reconciliation. The administrator reported 123 residents received medications in the facility. Findings: A policy titled Medication Storage in the Facility, dated January 2022, read in part, .Completed accountability records are submitted to the director of nursing and kept on file for 5 years at the facility . A facility policy titled Specific Medication Administration Procedure, dated January 2022, read in part, Chart medication administration on Medication Administration Record immediately following each resident's medication administration. Resident #110 had diagnosis which included an unspecified fracture of right pubis. A physician order, dated 03/15/24, documented oxycodone (opioid medication) 5 mg. Give one table by mouth every 4 hours as needed for pain. The order was discontinued on 07/31/24. A review of the MARS for March, April, May, June, and July of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors for one (#4) of four sampled residents who were observed during medication administration. The DON identified 123 residents who received medication in the facility. Findings: The Specific Medication Administration policy, dated January 2022, read in parts, .For liquid medications: Pour correct amount directly into a graduated/calibrated medication cup or measuring device or pull up correct amount into an oral syringe .Any dropper supplied with a medication should be used to measure dose. If none is supplied, oral dosing syringes with appropriate calibrations are used . Resident #4 had diagnoses which included seizures. The Care Plan, dated 08/01/24, documented the resident had seizures and to administer Dilantin (anti-epileptic medication) as ordered by the physician. The Laboratory Report, dated 08/09/24, read in part, .Dilantin .Abnormal 3 L .Reference Range .10-20 mg/L . The Physician's Order, dated 08/10/24, documented the resident was to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure medications were dated when opened for four (200 hall medication cart, 200/400 hall treatment cart, 100/300 hall treatment cart, and the 600 hall medication cart) of four medication/treatment carts observed. The DON identified eight medication/treatment carts in the facility. Findings: On 09/20/24 at 11:50 a.m., the 200 hall medication cart was observed with CMA #2. Ventolin inhaler for Resident #35 was observed to be opened, but not dated. On 09/20/24 at 12:02 p.m., the 200/400 treatment cart was observed with LPN #1. LPN #1 stated they were to date medications when they were opened. The following medications were observed to be opened but not dated. a. insulin lispro (diabetic medication) for Resident #115; b. fluticasone propionate inhaler for Resident #83; c. Trelegy inhaler and an albuterol inhaler for Resident #224; and d. one bottle of glucometer test strips. On 09/20/24 at 12:21 p.m., the 100/300 hall treatment cart was observed with LPN #3. The following medications were observed to be opened but not dated.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure dependent residents were offered/provided showers for two (#2 and #4) of six sampled residents who were reviewed for ADL care. The DON identified 63 residents who were dependent on staff for bathing. Findings: 1. Resident #2 had diagnoses which included fracture of the left femur. The five day assessment, dated 11/26/23, documented Resident #2 required moderate assistance from staff with bathing. A Skilled Nurses Note, dated 11/28/23, documented the resident had received a shower. Review of the electronic health record revealed one shower/bath had been offered/provided from 11/20/23 through 12/02/23. On 04/19/24 at 3:33 p.m., Regional Nurse #1 stated they had reviewed the electronic health record and did not find documentation baths/showers had been offered/provided other than 11/28/23 for Resident #2. 2. Resident #4 admitted with diagnoses which included right and left humerus fractures. The admission assessment, dated 04/07/24, documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure weights were monitored as ordered by the physician for two (#4 and #8) of five sampled residents reviewed for nutrition. The DON identified nine residents who had experienced significant weight loss. Findings: The Weight List policy, dated 10/21/09, read in part, .Residents weights are routinely and systematically monitored . 1. Resident #8 had diagnoses which included osteoporosis. The Care Plan, dated 02/13/24, documented the resident was at risk for a nutritional problem related to anemia and GERD and an intervention for weekly weights. The electronic health record, dated 03/07/24, documented a weight of 83.6 pounds. A Physician's Order, dated 03/14/24, documented to obtain weekly weights every seven days for weight loss. The Treatment Administration Record, dated 03/14/24 through 03/31/24, documented a weight had been obtained on 03/18/24 and 03/25/24. The electronic health record did not contain documentation of the value of the weight. The Treatment Administration Record, dated 04/01/24 through 04/18/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure snacks were provided for four (#2, 6, 9, and #10) of five residents reviewed for nutrition. The DON identified 27 residents who were diabetic. Findings: 1. Resident #2 had diagnoses which included diabetes mellitus. The Documentation Survey Report v2, dated November 2023, did not contain documentation snacks had been offered/provided from 11/20/23 through 11/30/23. The Documentation Survey Report v2, dated December 2023, did not reveal snacks had been offered/provided on 12/01/23. 2. Resident #6 had diagnoses which included diabetes mellitus. Review of the electronic health record, dated 04/09/24 through 04/18/24, did not reveal snacks had been offered/provided. On 04/19/24 at 4:07 p.m., Resident #6 stated they were not offered snacks and was unaware they were available. 3. Resident #10 had diagnoses which included GERD. The admission assessment, dated 01/30/24, documented the resident was cognitively intact for daily decision making. Review of the electronic health record, dated 04/19/24, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure notification to the physician of a change in status for one (#1) of three residents reviewed for notification of change. The Business Office Manager identified 126 residents who resided in the facility. Findings: A Resident's Family or Physician Notification of Change Guideline policy, effective 12/01/09, read in parts, .The facility will .consult with the resident's physician .a significant change in the resident's physical, mental, or psychosocial status . Resident #1 had diagnoses which included congestive heart failure, chronic kidney disease, and a sacrum pressure ulcer. A Physician's Order, dated 04/04/24, documented to obtain blood pressure twice a day and to report to the physician if the systolic blood pressures were greater than 170 or below 90, and if diastolic blood pressure was greater than 100 or below 70. The Medication Administration Record, dated April 2024, documented a blood pressure of 99/59 at 6:00 p.m. on 04/11/24 and a blood pressure of 78/40 on 04/12/24. Review of the progress notes did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure wound care was provided as ordered for one (#1) of three residents reviewed for pressure wounds. The DON identified 18 residents with pressure wounds. Findings: Resident #1 was admitted with diagnoses which included a sacral pressure ulcer. A Physician's order, dated 03/07/24, documented to cleanse the sacrum with normal saline, apply medihoney/durafiber ag (silver), and cover with bordered foam daily. The Treatment Administration Record, dated March 2024, revealed wound care had not been documented as completed eight times out of 22 opportunities. A Physician's Order, dated 03/14/24, documented to paint the left heel with skin prep and leave open to air every shift and as needed. The Treatment Administration Record, dated March 2024, documented the left heel wound treatment had not been documented as completed nine times out of 31 opportunities. A Physician's Order, dated 04/04/24, documented to cleanse the sacrum wound with normal saline, pack wound with dakins soaked gauze, cover with an ABD (abdominal) pad, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure pain management was provided for one (#1) of three sampled residents who were reviewed for pain management. The DON identified six residents who received routine pain medication. Findings: Resident #1 had diagnoses which included a sacral pressure wound and fracture of the sixth and seventh cervical spine. A Physician's Order, dated 04/05/24, documented to administer hydrocodone/acetaminophen 5/325 mg one tablet by mouth every six hours for pain. The Medication Administration Record, dated April 2024, did not contain documentation of the effectiveness of the pain medication. Review of the electronic health record did not reveal documentation of the effectiveness of the routine pain medication. On 04/18/24 at 1:39 p.m., CMA #1 stated they did not monitor for effectiveness of routine pain medication. On 04/18/24 at 1:50 p.m., LPN #1 stated they did not document the effectiveness of routine pain medication. They stated staff asked the resident if the medication were effective but do not document the response. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure bathing was offered/provided to dependent residents for one (#1) of three sampled residents who were reviewed for ADL assistance. The DON identified 77 residents who were dependent on staff for bathing. Findings: Resident #1 had diagnoses which included chronic pain. The quarterly assessment, dated 09/09/23, documented the resident was cognitively intact for daily decision making and was dependent on staff for bathing. The Documentation Survey Report v2, dated October 2023, documented the resident was scheduled a bed bath on Mondays and Fridays. The report documented Resident #1 had been offered or received five baths out of eight opportunities. The Documentation Survey Report v2, dated November 2023, documented the resident was scheduled a bed bath on Mondays and Fridays. The report documented Resident #1 had been offered or received three baths out of eight opportunities. On 12/04/23 at 1:38 p.m., Resident #1 stated they preferred a bed bath and were not offered bed baths as scheduled. On 12/05/23 at 10:33 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were provided a written notice of transfer for one (#105) of one sampled residents who were reviewed for hospitalization. The Resident Census and Conditions of Residents form, dated 08/21/23, identified 109 residents who resided in the facility. Findings: Resident #105 had diagnoses which included atrial fibrillation. The Discharge summary, dated [DATE], documented the resident was transferred to the hospital for complaints of shortness of breath and wheezing. Review of the clinical record did not reveal the resident/resident representative or the ombudsman had been provided written notification of the transfer to the hospital. On 08/28/23 at 11:09 a.m., the DON was asked who was responsible to to provide written notification of the transfer to the hospital to the resident and/or the resident representative and the ombudsman. They stated they would find out. On 08/28/23 at 11:25 a.m., RN #1, accompanied by the DON, stated they did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were provided a copy of the bed hold policy upon transfer to the hospital for one (#105) of one sampled residents who were reviewed for hospitalization. The Resident Census and Conditions of Residents form, dated 08/21/23, identified 109 residents who resided in the facility. Findings: The Bed Hold Policy, dated 01/23/08, read in part, .Resident shall be given notice of the bed hold option at the time of hospitalization or other leave . Resident #105 had diagnoses which included atrial fibrillation. The Discharge summary, dated [DATE], documented the resident was transferred to the hospital for complaints of shortness of breath and wheezing. Review of the clinical record did not reveal the resident/resident representative had been provided a copy of the bed hold policy when the resident was sent to the hospital. On 08/28/23 at 12:37 p.m., the DON was asked who was responsible to provide a copy of the bed hold policy upon transfer to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure dependent residents were assisted with oral care for one (#9) of five sampled residents who were reviewed for activities of daily living. The Resident Census and Conditions of Residents form, dated 08/21/23, identified 109 residents who resided in the facility. Findings: Resident #9 had diagnoses which included The significant change assessment, dated 05/21/23, documented the resident required extensive assistance of one staff member for personal hygiene and was cognitively intact for daily decision making. The Care Plan, revised 05/26/23, documented the resident had an ADL self care performance deficit related to limited mobility and required extensive assistance of one staff member for personal hygiene. The Documentation Survey Report v2 form, dated June 2023, documented the resident was offered oral hygiene two times out of 90 opportunities. The Documentation Survey Report v2 form, dated July 2023, documented the resident was offered oral hygiene one time out of 93 opportunities. The Documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.