Sequoyah East Nursing Center, LLC

Based on record review and interview, the facility failed to ensure hospice services were included on the care plan for 1 (#36) of 1 sampled resident reviewed for hospice. The DON reported 51 residents resided in the facility. Findings: An undated facility policy titled Care Plans, Comprehensive Person-Centered, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A care plan, initiated 05/01/23, showed Resident #36 had diagnoses which included malignant neoplasm of prostate (prostate cancer) and depression. A quarterly assessment, dated 02/14/25, showed Resident #36 had a BIMS score (a test for cognitive functioning) of 11, which was indicative of moderate impairment for daily decision making. A physician's order, dated 02/28/25, showed Resident #36 was admitted to hospice services for liver cell carcinoma. A care plan, edited 01/01/25, was reviewed and did not include hospice services. On 04/16/25 at 11:17 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.

Based on observation, record review, and interview, the facility failed to assess a resident for smoking safety prior to a resident smoking at the facility for 1 (#103) of 5 sampled residents reviewed for accident hazards. The DON identified 10 residents who smoked at the facility. Findings: On 04/14/25 at 1:01 p.m., Resident #103 was observed in their room lying in bed watching television. Two packs of cigarettes were observed on the resident's bedside table. On 04/15/25 at 2:39 p.m., Resident #103 was observed smoking in an indoor smoking room while supervised by a staff member. A facility policy titled Smoking Policy - Residents, dated October 2023, read in part, Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of smoking consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc. [further/similar things]); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). A facility document titled Sequoyah East…

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 facilty failed to ensure a resident with bed rails was assessed for the use of the bed rail for 1 (#45) of 1 sampled resident who was reviewed for bed rails. Corporate Nurse Consultant #1 identified eight residents who utilized bed rails in the facility. Findings: On 04/14/25 at 2:12 p.m., an enabler/assist bed rail was observed on the left side of Resident #45's bed. Resident #45 was observed to pace in the in the hallway. On 04/15/25 at 7:49 a.m., Resident #45 was observed in bed with an enabler/assist bed rail, on the left side of the bed, in the up position. On 04/15/25 at 11:45 a.m., Resident #45 was observed in bed with an enabler/assist bed rail, on the left side of the bed, in the up position. A policy titled Bed Safety and Bed Rails, dated August 2022, read in part, Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted.If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. The…

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 a urine sample was successfully cultured prior to the use of an antibiotic medication for a suspected urinary tract infection for 1 (#40) of 2 sampled residents reviewed for antibiotic use. The IP reported there were six residents prescribed antibiotics at the facility. Findings: A facility policy titled Surveillance for Infections, dated September 2017, read in part, When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. A facility document titled Individual Resident Infection Report, dated 04/07/25, showed Resident #40 had hematuria (blood in the urine), the resident had a possible UTI, the resident had not had a urine culture done, and showed the medication order for Bactrim DS (an antibiotic medication) twice daily for 10 days. A physician's medication order, 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 record review and interview, the facility failed to ensure resident medical records were safeguarded against unauthorized use. The administrator stated 48 residents resided in the facility. Findings: A facility document titled Notice of Privacy Practice's Acknowledgement documented newly hired staff members signed they had received a copy of Sequoyah Manor's Notice of Privacy Practices. A facility document titled HIPPA Residents Rights Implementation read in parts, .Sequoyah Manor will take reasonable steps to limit the use or disclosure of and requests for protected health information to the minimum necessary to accomplish the intended purpose . 1. A list of terminated employees documented LPN #1 had left the employment of the facility on 03/01/24. A PHI audit log documented LPN #1 had accessed 11 different areas in the EHR charting system including five areas of Res #5's documentation. On 04/10/24 at 3:30 p.m., the administrator stated this employee's last date to work was 02/27/24. The administrator stated they had been told by other employees LPN #1 was in an office 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 implement facility policy and procedures to ensure that applicants employment history and references were checked; and ensure that applicants registry checks were completed prior to employment. The administrator reported the census was 45. Findings: A facility policy titled Background Check Policy, read in part, The background checks of new employees will be completed prior to the first day of assigned work. The background check results will be documented in the employee file and kept confidential .Following the application, interview, and decision to hire, an offer of employment will be made pending a background check consisting of at least the following: prior employment verification, reference check, license verification and criminal background check . If all background checks meet the facility standards, the applicant will be offered the position . On 03/04/24 at 10:23 a.m., the buisiness office manager stated that they were responsible for checking applicants employment history and references. They also stated that…

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 staff failed to report allegations of abuse to their administrator within the timeframe indicated in state regulations for four (#1, 2, 3, and #7) seven sampled residents reviewed for abuse. A facility resident roster, dated 02/29/24, documented 45 residents resided in the facility. Findings: A facility abuse reporting and investigation policy, dated September 2022, read in part, .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of an unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury . 1. Resident #1 had diagnoses which included dementia, anxiety, and heart failure. An annual assessment, dated 12/21/23, documented the resident's cognition was intact. An incident report, incident date 02/08/24, documented an allegation of abuse which involved Resident #1 and CNA #2. It further documented the…

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 revise resident care plans related to falls for three (#1, 5, and #6) of seven sampled residents reviewed for abuse and neglect. A facility resident roster, dated [DATE], documented 45 residents resided in the facility. Findings: A Goals and Objectives, Care Plan policy, dated [DATE], read in part, .Goals and Objectives are reviewed and/or revised: a. when there has been a significant change in the resident condition; b. when the desired outcome has not been reached; c. when the resident has been readmitted to the facility from a hospital /rehabilitation stay; and d. at least quarterly . 1. Resident #1 had diagnoses which included dementia, anxiety, and heart failure. A facility face sheet documented Resident #1 was admitted to the facility on [DATE] and discharged [DATE]. A review of Resident #1's progress notes from [DATE] through [DATE] found the resident had eight falls during that period. Three of the falls resulted in injury. On [DATE] the…

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 Interview and record review it was determined the facility failed to ensure showers were given as ordered for two (#5 and #6) of three residents reviewed for bathing. The administrator reported the census was 45. Findings: 1. Resident #5 had diagnoses which included hypertension and emphysema. A Medicare 5-day assessment, dated 11/15/23, documented the resident was severely impaired for daily decision making and required moderate assistance with ADL's. A point of care history sheet, dated February 2024, documented the resident had received two showers and refused two showers during the month of February 2024. 2. Resident #6 had diagnoses which included mild intellectual disabilities and anxiety. A quarterly assessment, dated 02/10/24, documented the resident was moderately impaired for daily decision making and required partial assistance from staff. A point of care history sheet, Dated February 2024, documented Resident #6 had received two showers and refused three showers during the month of February 2024. On 03/05/24 at 8:50 a.m., CNA #8 was asked to review the February…

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 reviews and interviews the facility failed to ensure a certified nurse aide did not use their bare hands while providing personal care to residents for two (#2 and #3) of seven sampled residents reviewed for abuse. A resident roster, dated 02/29/24, documented 45 residents resided in the facility. Findings: A facility policy titled, Standard Precautions, dated September 2022, read in part, .Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease . 1. Resident #2 had diagnoses which included vascular dementia and cerebrovascular disease. A quarterly assessment, dated 12/16/23, documented Resident #2's cognition was severely impaired. 2. Resident #3 had diagnoses which included neurocognitive disorder with Lewy bodies and chronic obstructive pulmonary disease. A quarterly assessment, dated 12/08/23, documented Resident #3's cognition was severely impaired. A handwritten statement by CNA #6, dated 02/17/24, documented CNA #1 had been observed putting their bare hand down the brief 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 record review and interview, the facility failed to ensure the resident's representative was notified of transfer for one (#6) of 1 resident who was reviewed for notification of change. The administrator reported the census was 45. Findings: Resident #6 had diagnoses which included mild intellectual disabilities and a fractured left femur. A quarterly assessment, dated 02/10/24, documented the resident was moderately impaired for daily decision making and required moderate assistance from staff. A nurse noted dated 03/01/24 at 4:10 p.m., documented the resident had been transferred to another facility for therapy. A review of the resident's record did not document the resident's representative had been notified of the transfer. On 03/05/24 at 11:00 a.m., the administrator stated they did not notify the resident's representative because they thought the facility the resident transferred to had contacted them. On 03/07/24 at 10:00 a.m., the administrator stated that when a resident transfers the resident's representative should be notified, and it should be documented in the…

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 prevent a certified nurse aide from mentally abusing one (#7) of seven sampled residents reviewed for abuse. A facility resident roster, dated 02/29/24, documented 45 residents resided in the facility. Findings: A facility abuse reporting and investigation policy, dated September 2022, read in part, .Abuse is defined . the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish . Resident #7 had diagnoses which included dementia and psychosis. A quarterly assessment, dated 02/07/24, documented Resident #4's cognition was moderately impaired. A progress note, dated 02/04/24 at 1:01 p.m., documented Resident #7 had made the statement, The Indians are after me and they are going to kill my children. It further documented the staff changed the television channel away from a channel that showed old movies. A progress note, dated 02/04/24 at 5:22 p.m., documented Resident #7 again made statements about Indians eating children as well as the regret…

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 prevent a licensed nurse from allowing a staff member to work outside their scope of practice by attempting a blood draw for one (#2) of seven residents reviewed for abuse. A facility resident roster, dated 02/29/24, documented 45 residents resided in the facility. Findings: A facility policy and procedure, titled Obtaining Blood Specimens from a Direct Venipuncture, revised date March 2022, read in part, .The purpose of this procedure is to provide guidelines for the safe and aseptic sampling of the resident's blood via direct venipuncture . Resident #2 had diagnoses which included vascular dementia and cerebrovascular disease. On 02/29/24 at 11:06 a.m., the ADON stated they had observed the SSD attempt to collect a blood sample from Resident #2. They stated the SSD did use a phlebotomy set to attempt the blood draw in one arm of the resident and check the other arm for a good site. They stated they told the SSD not to try again as the resident would require hydration. They stated they did not give the SSD directions 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 record review and interview, it was determined the facility failed to ensure a facility assessment was updated annually. The administrator identified 45 residents resided in the facility. Findings: On 12/04/23 at 10:39 a.m., an entrance conference was conducted with the administrator. They were made aware a facility assessment was required to be provided within four hours of entrance. There was no documentation a facility assessment had been updated annually. On 12/05/23 at 1:53 p.m., the administrator stated they did not have a facility assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 8. Res #27 had diagnoses which included COPD, GERD, type 2 diabetes mellitus, unspecified viral hepatitis C, pain, depression, and anxiety. The EHR documented a quarterly resident assessment was due on 11/06/23 and the status of the assessment was late. On 12/06/23 at 12:47 p.m., MDS Coordinator #1 was asked when the last quarterly resident assessment was completed for the resident. They reviewed the EHR and stated a quarterly assessment was due on 11/06/23. They stated it was not completed. Based on record review and interview, the facility failed to ensure residents were assessed every three months using the quarterly review instrument for eight (#2, 18, 25, 26, 27, 35, 40, #42) of 15 sampled residents whose MDS assessments were reviewed. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.18.11 October 2023 documented in part .RAI…

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 physicians orders were followed for administering 02 for two (#5 and #15) of two sampled residents reviewed for respiratory care. The administrator identified nine residents who received O2. Findings: 1. Res #5 had diagnoses which included congested heart failure. A physician order, dated 03/17/23, documented O2 via nasal cannula at 2 LPM to maintain O2 saturation above 89 percent twice a day PRN. On 12/04/23 at 1:00 p.m., the resident was observed with O2, but the prongs of the nasal cannula were not in their nostrils. The O2 setting on the concentrator was 4 1/2 to 5 LPM. On 12/05/23 at 11:55 a.m., the resident was observed with O2 in place. The O2 setting on the concentrator was 3 LPM. 2. Res #15 had diagnoses which included COPD. A physician order, dated 01/03/23, documented O2 at 2 LPM via nasal cannula to keep O2 saturation above 89 percent. On 12/04/23 at 12:39 p.m., the resident was observed with O2 in place. The O2 setting on the concentrator was 3 LPM. On 12/05/23 at 11:23 a.m., the resident…

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: a. PRN psychotropic medications were limited to 14 days for two (#15 and #39), b. side effect monitoring was conducted for the use of psychotropic medications for one (#27), and c. unnecessary psychotropic medications were not administered for one (#27) of six sampled residents reviewed for medications. The administrator identified 39 residents who had orders for routine psychotpice medications and seven residents who had orders for PRN psychotropic medications. Findings: 1. Res #15 had diagnoses which included anxiety. A physician order, dated 11/04/23, documented lorazepam (antianxiety medication) 2 mg/ml. Give 0.25 ml by mouth every four hours PRN. There was no documentation the medication was limited to 14 days or a rationale to extend the medication. The November and December 2023 MARs were reviewed. It was documented lorazepam was administered one out of one opportunity beyond the 14 day limit. 2. Res #39 had diagnoses which included unspecified dementia with agitation. A physician order, 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 refrigerated medications were stored in a manner to maintain the integrity of the medications and failed to dispose of expired medications. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. The administrator stated all 45 residents received medications. Findings: On 12/07/23 at 12:40 p.m., a tour of the medication room on hall 500 was conducted. A black mini-fridge was observed with a blue plastic storage container in the door of the refrigerator. The container was removed and ice was observed flaking from the bagged medication in the container. Upon lifting one of the medications from the container it was observed the medications were stuck together in approximately 1 inch of ice in the bottom of the container. There was approximately 1/2 inch of water remaining in the container when the ice was lifted. The medications extracted from the ice included 12 separate plastic bags containing bisacodyl suppositories, two of which had standing…

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 labs were collected as ordered by the physician for one (#27) of five sampled residents reviewed for lab services. The administrator identified 45 resident resided in the facility. Findings: Res #27 had diagnoses which included type 2 diabetes mellitus, neuromuscular dysfunctional bladder, and unspecified viral hepatitis C. A physician order, dated 02/06/23, documented to collect a CBC, CMP, HbA1c, lipid panel, TSH in March, June, September, and December. It documented to collect an urine microalbumin annually in September. There was no documentation a CBC, CMP, HbA1c, lipid panel, and TSH were collected in March and September 2023. There was no documentation an urine microalbumin was collected in September 2023. On 12/06/23 at 12:39 p.m., the DON was asked to provide documentation the above labs were collected. On 12/06/23 at 2:08 p.m., the DON stated the labs were not collected.

Based on record review and interview, the facility failed to establish an infection surveillance program and failed to follow infection control practices during medication pass. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. Findings: A facility policy, titled, Administering Medications, revised December 2012, read in parts, .Policy Interpretation and Implementation .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications . 1. On 12/05/23 at 1:20 p.m. the infection control surveillance program documentation was requested. On 12/05/23 at 1:52 p.m., the administrator stated they did not have any documentation infections were being tracked or monitored. They stated they were unsure if an infection surveillance program was established in the facility. On 12/05/23 at 2:02 p.m., the administrator stated there was not an established program in the facility to track infections…

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 establish an antibiotic stewardship program. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. Findings: 1. On 12/05/23 at 1:20 p.m. the antibiotic stewardship program documentation was requested. On 12/05/23 at 1:52 p.m., the administrator stated they did not have any documentation of antibiotic stewardship. They stated they were unsure if an antibiotic stewardship program was established in the facility. On 12/05/23 at 2:02 p.m., the administrator stated there were not established protocols or a system to monitor antibiotic use.

Based on record review, observation, and interview, the facility failed to ensure resident call lights were in reach for one (#20) of 16 residents observed for call lights. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. Findings: A facility policy, titled, Answering the Call Light, revised October 2010, read in parts, .General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #20 had diagnoses which included cerebrovascular disease, vascular dementia with behavioral disturbance, seizures, and pain. A quarterly assessment, dated 09/15/23, documented the resident was severely impaired in cognition, was totally dependent on staff for most all ADL's, was incontinent of bladder and bowel, and received anti-anxiety and hypnotic medications. On 12/04/23 at 11:07 a.m., Res #20 was asked where their call light was. They stated they had not seen a call light in a very long time. The resident's call light was observed laying…

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 comprehensive resident assessment was completed for one (#39) of 13 sampled residents whose clinical records were reviewed for resident assessments. The administrator identified 45 residents resided in the facility. Findings: Res #39 was admitted to the facility on [DATE] with diagnoses which included dementia with agitation, pain, HTN, and pain. The EHR documented an annual resident assessment was due on 11/07/23 and the status of the assessment was late. On 12/05/23 at 10:01 a.m., MDS Coordinator #1 was asked when the annual resident assessment was completed for the resident. They reviewed the EHR and stated they missed completing the annual assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a significant change assessment within 14 days after a resident received hospice services for one (#25) of three sampled residents who were receiving hospice services. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. Findings: Resident #25 was admitted to the facility on [DATE] and had diagnoses which included severe dementia with agitation, chronic atrial fibrillation, and hypertension. A significant change in status assessment, dated 01/11/23, documented the resident was moderately cognitively impaired, and required extensive assistance with most all activities of daily living. A physician order, dated 03/07/23, documented to admit the resident to hospice services. On 12/05/23 at 11:24 a.m., the MDS coordinator was asked if a significant change assessment had been completed within 14 days of the resident being admitted to hospice services. They stated a…

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 notify the state authority of a new mental health diagnoses for one (#25) of two sampled residents reviewed for PASRR's. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. Findings: A level I PASRR screen, dated 04/06/21, documented Res #25 was screened and a level I was completed. It was documented there were no indicators for a level II PASRR. On 06/21/2022, Res #25 received a new diagnosis of bipolar disorder. There was no documentation the state authority had been notified of the resident's new diagnoses to see if a level II PASRR was required. On 12/05/23 at 11:24 a.m., the MDS coordinator stated Res #25's level one PASRR documented no serious mental illness. They stated they should have notified the state authority of the new bipolar diagnosis.

Based on record review, interview, and observation the facility failed to ensure PEG tube feeding containers were properly labeled for one (#20) of one sampled resident observed with PEG tube feedings. The MDS coordinator identified three residents receiving PEG tube feedings. Findings: A facility policy, titled, Enteral Feedings-Safety Precautions policy, revised May 2014, read in parts, .Preventing errors in administration .2. On the formula label document initials, date and time the formula was hung/administered . Resident #20 had diagnoses which included cerebrovascular disease, gastrostomy status, abnormal weight loss, dysphagia, and vascular dementia. A physician's order, dated 05/19/23, documented to administer Jevity 1.5 at 50 ml/hr continuous via peg tube with 60 ml/hr continuous water. On 12/04/23 at 11:36 a.m., a container of Jevity 1.5 on a continuous pump running at 50 ml/hr was observed. There was no date, time, or nurse initials on the Jevity container. On 12/06/23 at 9:21 a.m., LPN #2 was asked what the facility policy was when hanging a new Jevity container. They…

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 administer medications as ordered for one (#3) of six sampled residents reviewed for medications. The DON identified there were no residents who had physician orders to self administer medications. Findings: An Administering Medications policy, revised 12/2012, read in parts, .Medications shall be administered in a safe .manner, and as prescribed .Medications must be administered in accordnace with the orders .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . Res #3 had diagnoses which included COPD. A physician order, dated 03/15/23, documented ipratropium albuterol (bronchodilator) solution for nebulization 0.5 mg-3 mg (2.5 mg base)/3 ml one vial four times a day. On 12/05/23 at 3:12 p.m., the resident was observed seated on the side of their bed with a nebulizer mask covering their nose and mouth. Medication was observed being filtered…

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 the physician responded to pharmacist DRRs for one (#27) of five sampled residents reviewed for unnecessary medications. The administrator identified 45 residents resided in the facility. Findings: Resident #27 had diagnoses which included overactive bladder. A DRR, dated 06/06/23, documented the pharmacist made a recommendation to reduce ditropan (antimuscarinic medication) from TID to BID. There was no documentation the physician reviewed and responded to the recommendation. A DRR, dated 09/06/23, documented the pharmacist made a recommendation to reduce ditropan from TID to BID. There was no documentation the physician responded to the recommendation. On 12/06/23 at 12:39 p.m., the DON was asked was shown the DRRs for June and September 2023. They were asked to locate documentation the physician had responded to the recommendations. They stated they would not have a response to the June DRR. On 12/06/23 at 2:08 p.m., the DON stated they did not have documentation the physician responded to the DRRs. They stated…

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 the medication error rate was less than 5%. A total of 25 opportunities were observed with three errors. The total medication error rate was 12.0%. A Long-Term Care Facility Application for Medicare and Medicaid, dated 12/05/23, documented 45 residents resided in the facility. Findings: Res #29's physician order, dated 12/04/23, documented to administer florastor 250 mg by mouth twice daily for abnormal weight loss. On 12/06/23 at 8:48 a.m. CMA #1 asked LPN #2 if they were supposed to administer the florastor. LPN #2 stated no because it was the same med as the lactinex. On 12/06/23 at 8:55 a.m., CMA #1 was observed during medication pass to crush and administer enteric coated ferrous sulfate 325 mg tablet and a potassium chloride tablet ER 10 meq. On 12/06/23 at 9:12 a.m., CMA #1 was asked if they administered any medications that should not be crushed according to the standards of practice. They stated the potassium chloride tablet ER. On 12/06/23 at 9:17 a.m. LPN #2 was asked to review the resident's…

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 that properly trained personnel (certified in CPR for Healthcare Providers) were available immediately 24 hours per day and/or maintained their certification to be able to provide CPR until emergency medical services arrived. The Resident Census and Conditions report, documented 50 residents resided in the facility. Findings: A facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation, dated [DATE], read in part Personnel have completed on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest .Preparation for Cardiopulmonary Resuscitation. 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel .3. Select and identify a CPR Team for each…

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 code status was documented correctly throughout the residents' clinical records for three (#1, 2, and #3) of nine residents reviewed for code status. The Resident Census and Conditions report, documented 50 residents resided in the facility. Findings: A facility policy titled Advance Directives, dated April 2013, read in part .7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive .16. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and /or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan . 1. Res #1 had diagnoses which included falls, weight loss, and dementia. A physician order, dated 05/09/23, documented the resident was a full code. A care plan, dated 07/21/23, documented the resident was a full code. The…

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 provide bathing assistance to residents who were unable to bathe themselves for three (#1, 2, and #3) of six residents sampled for ADL assistance. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: 1. Res #1 had diagnoses of cerebral infarction, shortness of breath, and muscle spasms. A point of care bathing records for the months of June, July, and August of 2023 documented 46 baths were not given out of 99 opportunities. A discharge assessment, dated 09/26/23, documented the resident required extensive assistance with most ADLs and did not receive a bath during the assessment period. On 10/03/23 at 2:13 p.m., CNA #2 stated the staffing was low so baths/showers were missed. 2. Res #2 had diagnoses of hypertension, left above knee amputation, right below knee amputation, and muscle spasms. A quarterly assessment, dated 08/06/23, documented the resident was intact in cognition and required assistance with bathing. On 10/03/23 at 1:10 p.m., Res #2 stated it had been…

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 implement proper infection prevention and control practices related to the transmission of COVID-19 for two (#3 and #5) of six sampled residents. The Resident Census and Conditions of Residents form documented 53 residents resided in the facility. Findings: A facility policy titled Coronavirus Disease (COVID-19) -Identification and Management of Ill Residents, revised 09/2022, read in part, .Resident Placement 1. Resident with suspected or confirmed SARS-CoV-2 infection are placed in a single-person room. The door will be kept closed (if safe to do so). Ideally, the resident will have a dedicated bathroom .4. Transport and movement of the resident outside of the room is limited to medically essential purposes .Duration of Transmission-Based Precautions (TBP) for residents with SARS-CoV2 Infection .18. Resident with mild to moderate illness who are not moderate to severely immunocomprimised will remain on transmission based precautions until: a. at least 10 days has passed since symptoms first appeared; and b. at least 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to inform and provide written information concerning the right to accept or refuse to formulate an advance directive for Res #16 and failed to ensure the DNR form for Res #27 included the authorized signature and date for two (#16 and #27) of five residents sampled for advanced directives. The Resident Census and Conditions of Residents form documented 40 residents with advanced directives. Findings: 1. Res #27 was admitted to the facility on [DATE]. A physician order, dated 12/31/12, documented Res #27's code status as DNR. The DNR document in the resident's record documented a family member's signature. The facility did not have POA or guardianship documentation which authorized the signer permission to sign the DNR document. The DNR document did not include a date. An annual assessment, dated 08/23/22, documented the resident had severely impaired cognition. On 10/19/22 at 3:23 p.m., the administrator stated the facility could not locate the paper work…

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 provide the ABN form CMS-10055 to residents who received skilled services and afterwards stayed in the facility for three (#1, 29, and #34) of three residents sampled for beneficiary protection notification review. The ADON identified 21 residents who had discharged from skilled services in the last six months. Findings: According to Res #1's medical record, Res #1 started skilled services on 07/01/22 and was discharged on 09/26/22. The ABN form was not provided. According to Res #29's medical record, Res #29 started skilled services on 07/05/22 and was discharged on 10/01/22. The ABN form was not provided. According to Res #34's medical record, Res #34 started skilled services on 07/08/22 and was discharged on 09/26/22. The ABN form was not provided. On 10/18/22 at 1:23 p.m., the ADON stated she did not know she had to give the ABN 10055 notice to the residents.

Based on observation and interview, the facility failed to ensure bath linens were available when needed for resident bathing. The Resident Census and Conditions of Residents form documented 56 residents resided in the facility. Findings: On 10/18/22 at 10:10 a.m., Res #3 stated she needed a shower because she had somewhere she needed to be at 10:30 a.m. The resident turned on the call light. On 10/18/22 at 10:13 a.m., CNA #1 answered the light. Res #3 stated she did not have time for a shower and needed a bed bath instead. She said I have something to do at 10:30. The CNA responded and stated, I don't have enough towels to give you a bed bath. When questioned, the CNA stated the facility ran out towels sometimes. On 10/18/22 at 10:25 a.m., the activity director/CMA was asked where the towels were stored in the facility. The 600 Hall linen closet had two towels and two wash cloths. The 500 Hall linen cart held one towel and three wash cloths. The 300 Hall closet held four towels and three wash cloths. The 300 Hall linen cart on the locked unit had three towels and two wash cloths.…

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, observation, and interview, the facility failed to correctly identify an individual with a mental disorder for two (#18 and #32) of two residents sampled for PASRR screening and failed to notify OHCA when residents received new mental illness diagnoses. The Resident Census and Conditions of Residents form documented 10 residents had documented psychiatric diagnoses. Findings: 1. Resident #32 was admitted on [DATE] with diagnoses which included generalized anxiety disorder and depression. The resident's medical record documented the resident had received a diagnosis of unspecified psychosis not due to a substance or known physiological condition on 08/26/22. An admission assessment, dated 08/30/22, documented Res #32 had delusions, anxiety disorder, psychotic disorder, was moderately impaired in cognition, and was independent to requiring limited assistance with ADLs. A care plan, initiated on 08/31/22, documented Res #32 received psychotropic medications and to assess if the resident's…

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, observation, and interview, the facility failed to develop a base-line care plan which documented all required components and failed to provide the base-line care plan to the resident or resident representative for two (#156 and #157) of 20 residents whose care plans were reviewed. The Matrix for Providers form documented four residents had been admitted in the previous 30 days. Findings: 1. Resident #156 was admitted on [DATE] and had diagnoses which included Alzheimer's disease, myalgia, and diabetes. An admission assessment was not available for review. A review of Res #156's medications documented the resident was to receive 11 different medications and was to received daily FSBS. A document titled, ''Interim Plan of Care,'' dated 10/14/22, was reviewed and did not document the physician ordered medications or treatments. On 10/18/22 at 7:15 a.m., Res #156 was observed sitting in his room with his wife. On 10/20/22 at 10:39 a.m., the MDS coordinator confirmed the base-line care plan…

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, observations, and interview, the facility failed to ensure residents were free of significant medication errors for one (#157) of five residents reviewed for medications. The Residents Census and Conditions of Residents form documented 56 residents resided in the facility. Findings: Res #157 had diagnoses which included dementia, disorder of the cornea, diabetes, hypothyroidism, and benign prostatic hyperplasia. A physician order, dated 10/06/22, documented the facility was to administer divalproex (an antiseizure medication) 125 mg three times daily for a diagnosis of dementia. A review of the resident's MAR revealed the facility did not provide the medication to the resident on one or more of the doses on 10/06/22, 10/07/22, 10/08/22, 10/12/22, and 10/13/22. A physician order, dated 10/06/22, documented the facility was to administer gabapentin (a medication used for neuropathy) 100 mg three times daily for a diagnosis of diabetes with polyneuropathy. A review of the resident MAR revealed the facility did not provide this medication to the resident 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, observation, and interview, the facility failed to develop a comprehensive care plan related to insulin use and diabetes for one (#44) of one residents reviewed for insulin use. The Resident Census and Conditions of Residents form documented 56 residents resided in the facility. Findings: Res #44 had diagnoses which included diabetes mellitus and hyperglycemia. A physician order, dated 09/01/22, documented the facility was to administer Novolog Flexpen Insulin four times daily per sliding scale for a diagnosis of DM. An admission assessment, dated 09/12/22, documented Res #44 was severely impaired in cognition and had a diagnosis of renal insufficiency and diabetes. The assessment documented the resident received insulin daily during the assessment period. A care plan for Res #44 was reviewed and did not document a plan of care for diabetes or insulin use. On 10/18/22 at 7:13 a.m., Res #44 was observed in her room sitting on a recliner. At that time, a family member stated the resident used insulin and stated the resident's blood sugar was frequently over 200…

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, observation, and interview, the facility failed to conduct regular weekly assessments on resident wounds for one (#44) of two residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents form documented four residents who resided in the facility had pressure ulcers. Findings: Resident #44 had diagnoses which included pressure ulcers of heel and sacral region, personal history of other venous thrombosis and embolism, local infection of the skin and subcutaneous tissue, and diabetes. An EHR entry under events, dated 09/06/22, documented the resident had a stage II pressure ulcer on the coccyx. The note documented the physician was notified and an order was received to clean the wound with wound cleanser, pat dry, apply collagen and Anasept and cover with Duoderm every three days until healed for 14 days then reevaluate. At that time, the coccyx wound was documented as 3.0 x 1.0 cm in size. A EHR entry under weekly wound assessment, dated 09/07/22, documented the…

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, observation, and interview, the facility failed to implement an intervention to prevent potential falls and update the care plan to reflect the intervention for one (#157) of one resident reviewed for falls. The Resident Census and Conditions of Residents form documented 56 residents resided in the facility. Findings: Res #157 had diagnoses which included dementia, diabetes, and cervical and intervetebral disc degeneration. An incident report form, dated 10/10/22, documented the resident had fell in his room, striking his forehead on the nightstand, sustaining a laceration to his head. The incident report documented an initial step to prevent recurrence of falls as non skid socks while in bed. The final incident report, dated 10/10/22, documented to place the resident on one hour visual checks for 30 days. A care plan, developed to prevent the recurrence of falls, dated 10/14/22, documented Res #157 had a history of falls related to being unaware of safety needs. The care plan documented an intervention for the fall which occured on 10/10/22 documenting…

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, observation, and interview, the facility failed to notify the physician of significant weight loss for one (#16) of two residents sampled for nutrition. The ''Resident Census and Conditions of Residents form documented five residents with unplanned significant weight loss/gain. Findings: Res #16 was admitted on [DATE] with diagnoses which included Alzheimer's disease, cerebral infarction, abnormal weight loss, dietary folate deficiency anemia, vitamin B12 deficiency anemia, malignant neoplasm of prostate, nausea with vomiting, and heartburn. The weight record, dated 05/11/22, documented the resident weighed 97.7 lbs. On 05/24/22 Remeron (an antidepressant) was ordered by the physician to help with abnormal weight loss. The weight record, dated 07/05/2022, documented the resident weighed 96.4 lbs. A quarterly assessment dated [DATE], documented the resident was moderately impaired in cognitive skills, independent with eating with set up help only, was 60'' tall, weighed 96 lbs and was 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.