Sequoyah Manor, LLC

Based on observation, record review, and interview, the facility failed to ensure residents were accurately assessed for bedrails for two (#30 and #48) of two sampled residents who were reviewed for bedrails. The DON identified nine residents who had bedrails. Findings: 1. Resident #30 had diagnoses which included pain and left sided hemiplegia. A Physician's Order, dated 05/11/21, documented the resident was to utilize quarter side rails bilaterally for repositioning. The Side Rail Consent, dated 08/15/24, documented the use of quarter side rails bilaterally. The Bed Rail/Assist Bar Evaluation, dated 12/02/24, did not indicate the type of bed rail evaluated. The MDS coordinator had completed the evaluation. On 12/16/24 at 3:48 p.m., Resident #30 was observed in bed with half side rails in the up position bilaterally. On 12/18/24 at 4:06 p.m., Resident #30 was observed in bed with half side rails in the up position bilaterally. On 12/19/24 at 11:19 a.m., the DON stated Resident #30 utilized side rails and was assessed quarterly by the MDS coordinator. They stated they thought 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 observation and interview, the facility failed to follow the menus for the residents. The DM identified the kitchen prepared meals for 64 residents. Findings: On 12/18/24 at 4:20 p.m., the evening meal was prepared by cook #1. The cook was preparing the pureed diet for the residents. The cook stated they were unsure how many ounces the breaded piece of chicken weighed. The cook weighed the breaded piece of chicken and stated it weighed 1.5 ounces. The cook stated the menu documented one patty per serving. On 12/18/24 at 4:38 p.m., the DM stated the recipe for a breaded chicken sandwich documented to serve one each breaded chicken piece equaling three ounces of meat. The DM stated they were not aware the breaded piece of chicken for the sandwich needed to weigh three ounces. They stated they only knew the menu called for one breaded piece of chicken. On 12/18/24 at 5:21 p.m., the DM stated peas and carrots was to be the vegetable for the evening meal. The DM stated corn was substituted because they did not have peas and carrots. The DM stated the entire meal menu prepared…

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 beds and side rails were regularly inspected as part of a maintenance program for two (#30 and #53) of three sampled residents who were reviewed for side rails. The DON identified nine residents who utilized side rails. Findings: The Bed Safety and Bed Rails policy, dated August 2022, read in part, Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. 1. Resident #30 had diagnoses which included pain and left sided hemiplegia. A Physician's Order, dated 05/11/21, documented the resident was to utilize quarter side rails bilaterally for repositioning. On 12/16/24 at 3:48 p.m., Resident #30 was observed in bed with half side rails in the up position bilaterally. 2. Resident #53 had diagnoses which included hemiplegia and hemiparesis. A Physician's Order, dated 09/05/23, documented the resident utilized one side rail to assist in bed mobility and transfers. On 12/18/24 at 4:08 p.m., Resident #53 was observed in bed with 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 contact a local law enforcement agency within the mandated time frame after being informed of an allegation of abuse for one (#1) of four sampled residents reviewed for abuse. The DON identified 71 residents resided at the facility. Findings: A facility policy titled Abuse Investigation and Reporting, dated July 2017, read in part, Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The stated licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. An Incident Report Form marked as an initial report, with…

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 the abuse policy for one (#5) of five sampled residents reviewed for abuse and failed to develop an abuse policy with appropriate reporting time frames. The administrator identified 70 residents who resided in the facility. Findings: The Abuse, Neglect, Exploitation General policy, dated 05/05/17, read in parts, .Facility will educate all staff about how to recognize signs of possible abuse .All facility employees .are educated that all alleged or suspected violations involving mistreatment, neglect or abuse .are reported IMMEDIATELY to the Administrator .In the event an incident that meets or has the potential to meet one of the definitions stated in the policy on abuse or neglect of an elder is reported to the Administrator or designee, an investigation of the incident will be commenced immediately. The Administrator will contact DHS immedieatly [sic] and the Oklahoma State Department of Health within 24 hours .Reporting .The DON, Administrator or other designated investigating individual will begin their own…

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 residents were free from verbal abuse for one (#5) of five sampled residents reviewed for abuse. The administrator identified 70 residents who resided in the facility. Findings: The Abuse, Neglect, Exploitation General policy, dated 05/05/17, read in parts, .Facility will educate all staff about how to recognize signs of possible abuse .All facility employees .are educated that all alleged or suspected violations involving mistreatment, neglect or abuse .are reported IMMEDIATELY to the Administrator . Resident #5 had diagnoses which included cerebral palsy and unspecified intellectual disabilities. The quarterly assessment, dated 07/05/24, documented the resident was moderately impaired in cognition for daily decision making. Resident #2 had diagnoses which included bipolar disorder. The quarterly assessment, dated 07/29/24, documented the resident was cognitively intact for daily decision making. The Event Report for Resident #2, dated 08/05/24 at 7:38 p.m., read in parts, .Progress Note .Resident witnessed being…

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 comprehensive care plans were person-centered for two (#1 and #2) of four sampled residents whose care plans were reviewed. Findings: The Care Plans, Comprehensive Person-Centered policy, dated December 2016, read in part, .The comprehensive, person-centered care plan will .reflect the resident's expressed wishes regarding care and treatment goals .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change . 1. Resident #1 had diagnoses which included Rett's syndrome. The quarterly assessment, dated 07/03/24, documented the resident was severely impaired in cognition for daily decision making. Review of the electronic clinical record, including the care plan, revised 08/29/24, did not reveal resident/resident representative preferences had been documented. On 09/10/24 at 2:08 p.m., dietary aide #1 stated they were aware Resident #1's mother did not want male residents around their loved one. They stated they had heard about the mother'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.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility with only one resident not receiving nutrition from the kitchen. Findings: The Foods Brought by Family/Visitors policy, dated December 2008, read in part, .6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be tabled with the resident's name the item and the 'used by' date . On 08/28/23 at 9:42 a.m., an initial tour of the kitchen was made and the following was observed. The trash can by the hand washing sink was not covered and there was food splatter on the wall behind the trash can. A cut cantaloupe was observed on a cookie sheet on the counter covered with wax paper. On 08/28/23 at 9:44 a.m., the refrigerator was observed to contain an open can of ravioli with a plastic cup lid covering the top and the metal can lid was down in the ravioli…

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 residents were offered the choice to formulate advance directives for two (#2, and #9) and failed to ensure a DNR was complete for one (#14) of six residents sampled for advanced directives. The Resident Census and Conditions of Residents report documented 31 residents who resided in the facility had advanced directives. Findings: A policy titled Advanced Directives, dated September 2022, read in part, .1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 1. Res #2 had diagnoses which included age related physical debility and diabetes mellitus. A physician order, dated 08/11/23, documented the resident was a full code. An admission assessment, dated 08/24/23, documented the resident was moderately impaired with cognition and requited extensive assistance with most ADLs. A care plan, dated 08/24/23, documented the resident preferred to be 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 observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed and/or implemented to address the residents' needs related to: a. a nutrition care plan for one (#46); b. hospice services and the use of an antipsychotic medication for one (#56); and c. the use of side rails and the resident's use of a vape device for one (#33) of 26 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: 1. Res #46 had diagnoses which included anorexia and muscle wasting. A quarterly assessment, dated 06/13/23 documented the resident was severely impaired in cognition, weight was 137 pounds, and they had not lost weight. A care plan, initiated on 07/11/23, documented the resident had an unplanned weight loss due to eating less at meals and refusing supplements at times. The care plan documented the registered dietitian was to review resident's medical record and make recommendations, nursing was to follow, and the dietary manager was to determine…

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 care plans were updated to meet the residents' current needs for one (#56) of 26 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: Res #56 had diagnoses which included heart failure. A DNR form, dated 12/02/22 and signed by the resident, documented the resident had elected to be a DNR. A care plan, dated 12/06/22, documented the resident preferred to be a full code. A physician order, dated 06/27/23, documented the resident was not to be resuscitated in the event of a cardiac or respiratory arrest. A physician order, dated 07/31/23, documented the resident was to be admitted to hospice care. On 08/29/23 at 7:57 a.m., the resident was observed in their room in their bed. The resident stated they were on hospice and hospice came in and gave them a bath a couple of times a week. On 08/31/23 at 9:55 a.m., MDS Coordinator #1 stated the care plan was not updated in regard to the resident code status. 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 observation, record review, and interview, the facility failed to ensure residents received showers, oral care, and nail care, as ordered for three (#2, 18, and #48) of six residents sampled for ADL care. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included age related physical debility, cerebral infarction, and diabetes mellitus. A physician order, dated 08/11/23, documented to give the resident a bath with hair and nail care three times a week and PRN. An admission assessment, dated 08/24/23, documented the resident was moderately impaired with cognition and required extensive assistance with most ADLs. A care plan, dated 08/24/23, documented the resident required assistance with bathing. A Point of Care history report, for August 2023, documented the resident had not received a bath from admission on [DATE] until 08/21/23. On 08/28/23 at 12:56 p.m., Res # 2 were observed in their bed and stated they had…

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 pressure ulcers treatments were completed as ordered for two (#18 and #19) and failed to ensure wound assessments were completed for one (#19) of four sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents form documented four residents had pressure ulcers. Findings: 1. Res #18 had diagnoses which included diabetes mellitus, paraplegia, and pressure ulcers. A physician order, dated 07/04/23, documented to cleanse full thickness wound to left ischium with wound cleanser and pat dry. The order documented to apply skin prep and pat dry; apply skin prep to peri wound and allow to dry; apply Anasept gel to wound bed; apply calcium alginate, cut to fit wound bed; and cover with silicone super absorbent dressing if available or silicone foam dressing BID. The order was discontinued on 08/25/23. A physician order, dated 07/04/23, documented to cleanse full thickness wound to right ischium with wound…

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 assess the resident for risk for entrapment, review the risks or benefits with the resident and/or their representative and obtain an informed consent, or attempt appropriate alternatives prior to installing bed or side rails for three (#13, 19, and #33) of eight sampled residents reviewed for accident hazards. The DON identified 21 residents whose beds were equipped with side rails. Findings: 1. Res #13 was admitted to the facility on [DATE] and had diagnoses which included rheumatoid arthritis, chronic bronchitis, tremors, chronic kidney disease, and muscle wasting and atrophy. A physician order, dated 01/24/20, documented the facility was to provide the resident with 1/4 side rails to aide with bed mobility, positioning, and transferring. A side rail assessment and consent form, dated 01/24/20, did not document the residents size and weight, sleep habits, medication, acute medical and surgical intervention, existence of delirium,…

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 have sufficient staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: 1. A physician order for Res #22, dated 05/13/23, documented the facility was to obtain daily weights for the resident as ordered by the resident's cardiologist. A review of the resident's weight records in the EHR documented during the months of July and August of 2023 the resident's weight had been obtained eight times. On 09/01/23 at 11:19 a.m., RA #1 stated they had been pulled to work the floor many times in the previous two months but especially in August. The RA stated it was their responsibility to obtain the residents' weight and had one resident who was on daily weights and stated it was Res #22. The RA stated the facility had pulled them to the floor 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 observation, record review, and interview, the facility failed to ensure residents were adequately monitored for adverse reactions to medications, goals for treatment, and providing an adequate indication for the medication use, for five (#13, 14, 32, 46, and #56) of five residents who were sampled for medications. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: A facility policy titled Anticoagulation - Clinical Protocol, revised 11/18, read in part, .1. The physician will prescribe anticoagulation therapy appropriately, consistent with recognized guidelines .2. The physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions with anticoagulants .5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. A facility policy titled Adverse Consequences and Medication Errors, revised 4/14, read in part, .4. The staff and practitioner shall strive to minimize…

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.

4. Res #14 had diagnoses which included diabetes mellitus, heart disease, hypertension, and major depressive disorder. A quarterly assessment, dated 06/27/23, documented resident was moderately impaired with cognition and required extensive assistance with most ADLs. The assessment documented the resident was taking an antidepressant, an anticoagulant, and a diuretic during the assessment period. A physician order, dated 07/24/23, documented Celexa (an antidepressant medication) administer daily for depression. A care plan, last reviewed 07/24/23, documented the staff were to monitor for effectiveness and side effects of medication use every shift. The MAR and TAR for July and August 2023 were reviewed and did not document target behaviors or monitoring for side effects for the medication Celexa. 5. Res #32 had diagnoses which included atrial fibrillation, diabetes mellitus, depression, and anxiety disorder. A physician order, dated 03/20/23, documented to administer doxepin (an antidepressant medication) at bedtime for insomnia. A physician order, dated 06/13/23, documented 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 the medication cart was kept locked or under direct observation of authorized staff and to implement the system in which the quantity stored of controlled medications was enacted so a missing dose could be readily detected. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: A facility policy titled Controlled Substances, dated 11/22, read in part, .3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services . On 08/29/23 at 2:32 p.m., the insulin medication/treatment cart was observed to have been unlocked and unattended in the hallway while LPN #5 was in the DON office speaking with staff. At that time, the LPN was interviewed and stated the cart should have been locked before they had left it unattended. On 08/31/23 at 4:10…

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 sufficient staff for food and nutrition services. The Resident Census and Conditions of Residents report, documented 60 residents resided in the facility and one resident did not eat from the kitchen. Findings: A document titled SEQUOYAH MANOR LLC MEAL SERVICE POLICY, revised 03/30/2022, read in part, Meals will be served on a routine schedule at set times. Mealtimes are planned according to existing norms in the community. Each client will receive a minimum of three meals daily with appropriate snacks to meet caloric needs .MEAL HOURS: .Breakfast 7:30 a.m. Lunch 12:00 p.m. Dinner 5:00 p.m . On 08/28/23 at 12:20 p.m., the lunch meal service had not started at this time. On 08/28/23 at 12:38 p.m., the first tray was observed to have been taken out to residents. On 08/31/23 07:38 a.m., breakfast had not started at this time. Eggs were observed being cooked at this time. A schedule for the dietary department, for the month of August 2023, documented four employees worked in the kitchen during the weekdays…

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 provide food that was palatable and at an appetizing temperature for the residents. The Resident Census and Conditions of Residents report, documented 60 residents resided in the facility, 20 with a mechanically altered diet and one resident with tube feedings. Findings: 1. On 08/30/23 at 12:09 p.m., the small steam cart for the locked unit unit was sent out of the kitchen. Temperatures of the food, which was placed on the steam cart, were not obtained before it was sent out to the unit. The food which was to be kept cold, was on the steam cart. The other pan of food to be kept cold did not fit and was placed on the second shelf of the cart and was not observed to have been on ice. On 08/30/23 at 12:22 a.m., the steam cart was observed on the unit. The potato salad temperature was 80.4 degrees F and the cucumber and onion salad was 60.8 degrees F. 2. On 08/30/23 at 12:22 p.m., meal service started in the dinning room. The kitchen staff were not observed to obtain temperatures of the food before service…

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 follow a therapeutic diet and menu for the residents who received a pureed diet. The Resident Census and Conditions of Residents form documented 20 residents received a mechanically altered diet. Findings: On 08/30/23 the menu for the lunch meal was documented to have been a meatball sub sandwich, potato salad, marinated cucumber and onion salad, and gooey butter bar. On 08/30/23 at 11:21 a.m., [NAME] #1 was observed to puree the potato salad. [NAME] #1 assisted [NAME] #2 to puree the cucumber and onion salad. The DM pureed the meat balls for the puree meals. On 08/30/23 at 12:22 p.m., the meal service started in the dining room. The puree residents were observed to receive meat balls, potato salad, and cucumber and onions salad, and a yogurt for dessert. The puree residents were not served bread of any kind or the gooey butter bar or the cake which was substituted for the bar for the regular diets. On 08/31/23 at 9:00 a.m., the DM was asked about the puree meals not receiving any bread with their meal. 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 observation, record review, and interview, the facility failed to implement and maintain an infection prevention and control program related to: a. the prevention of Legionellosis and Pontiac fever caused by Legionella bacteria. b. appropriate signage for TBP on the door of a room for a resident in isolation. c. the handling and transport of residents' soiled laundry. d. ensuring tubing and catheter bags were maintained in a location to prevent contamination. e. performing appropriate hand hygiene while serving and delivering meals on the locked unit. The Resident Census and Conditions of Residents report, documented 60 residents resided in the facility. Findings: A facility policy titled Isolation - Initiating Transmission Based Precautions, revised in April of 2012, read in part, .b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional…

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 conduct regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for three (#13, 19, and #33) of three sampled residents reviewed for bed rails. The DON identified 21 residents whose beds were equipped with side rails. Findings: Res #13, 19, and #33 were observed to have side rails attached to their beds. On 08/31/23 at 12:35 p.m., the maintenance supervisor was interviewed and stated they checked the residents' beds for cleanliness twice weekly but did not conduct inspections of the mattresses, frames, or bed rail inspections to identify areas of entrapment.

Based on observation, record review, and interview, the facility failed to ensure a resident or resident representative was informed in advance of the risk and/or benefit of the use of an antipsychotic medication for one (#56) of five residents reviewed for medications. The Resident Census and Conditions of Residents form documented eight residents received antipsychotic medications. Findings: Res #56 had diagnoses which included dementia. A physician order, dated 08/01/23, documented the facility was to administer 25 mg of Seroquel (an antipsychotic medication) at bedtime daily for a diagnosis of dementia with mood disturbance. A significant change assessment, dated 08/03/23, documented the resident was severely impaired in cognition; had verbal behaviors directed toward others and rejection of care behaviors; was independent to requiring limited assistance with ADLs; and received an antipsychotic mediation for two days of the seven day assessment period. On 08/29/23 at 7:57 a.m., the resident was observed lying in their bed. The resident stated they did not know what medications…

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 conduct a significant change assessment for one (#14) of 20 sampled residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: Res #14 had diagnoses which included heart disease, diabetes mellitus, and weight loss. A quarterly assessment, dated 03/23/23, documented the resident was intact with cognition; walked in their room with supervision; and weighed 122 pounds with no weight loss. A quarterly assessment, dated 06/27/23, documented the resident was moderately impaired with cognition; walked in their room with extensive assist of one staff person; weighed 113 pounds, and not on a physician prescribed weight loss regimen. On 08/31/23 at 7:20 a.m., MDS Coordinator #1 stated they thought the resident had to have three areas of decline in the ADL section. The MDS coordinator stated they were new to the position and they were instructed a significant change assessment was to be conducted when the ADL section indicated a change.

Based on record review and interview the facility failed to refer residents with newly evident or possible serious mental disorder to OHCA for evaluation for a level II PASRR assessment for one (#9) of three residents reviewed for PASRR and failed to ensure the PASRR level I assessment was correct. The Resident Census and Conditions of Residents form documented 24 residents had psychiatric diagnoses. Findings: The EHR documented Res #9 had received a diagnosis of other specified depressive episodes on 04/24/21. A PASRR level one assessment, dated 04/28/21, documented the resident did not have a diagnosis of mental illness or intellectual disabilities. The EHR documented the resident received a diagnosis of unspecified mood disorder on 11/03/21. The EHR documented the resident received a diagnosis of behavioral and emotional disorders with onset usually occurring in childhood and adolescence on 11/17/21. An annual assessment, dated 07/20/23, documented the resident was not considered to have a serious mental illness, was intact in cognition, required extensive assistance with ADLs,…

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 not using a vape in their rooms for one (#33) of eight residents sampled for accident hazards and failed to have a policy related to vaping in the facility. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: A facility policy titled SEQUOYAH MANOR SMOKING POLICY, dated 07/22/14, read in part, .3. Employees and residents must smoke in designated areas .11. All cigarettes, lighters, and e-cigarettes charges, must be kept in the medication room and dispensed according to the designated smoking hours . Res #33 had diagnoses which included heart failure, atrial fibrillation, and SOB. An admission assessment, dated 06/27/23, documented the resident was moderately impaired in cognition and required extensive assistance with ADLs. The assessment documented the resident did not use tobacco. A review of the resident's EHR did not contain an assessment for using a vape. On 08/28/23 at 3:42 p.m., Res #33 was observed to have two vapes, one…

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 maintain urinary catheters off of the floor to prevent possible infections for two (#33 and #48) of three resident reviewed for catheters. The Resident Census and Conditions of Residents form documented eight residents with indwelling catheters resided in the facility. Findings: 1. Res #33 had diagnoses which included retention of urine, benign prostatic hyperplasia without lower urinary tract symptoms, and urinary tract infection. An admission assessment, dated 06/27/23, documented the resident was moderately impaired with cognition, required extensive assistance with most ADLs, and had an indwelling catheter. On 08/28/23 at 3:40 p.m., the resident's catheter bag was observed touching the ground by the residents bed. Res #33 was not able to say how long they had the catheter. A nurse note, dated 08/30/23 at 9:17 p.m., documented the resident had purulent drainage from urethra and the physician was notified and gave a new order to obtain a UA. A physician order, dated 08/30/23, documented doxycycline hyclate…

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 residents were free from significant medication errors for one (#32) of five residnts reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented 60 residents resided in the facility. Findings: Res #32 had diagnoses which included atrial fibrillation, diabetes mellitus, and peripheral vascular diseases. A physician order, dated 09/29/21, documented the facility was to administer Novolog (insulin aspart u-100) solution; 100 unit/mL per sliding scale before meals and at bedtime for diabetes mellitus. A physician order, dated 11/28/22, documented to administer Lantus (insulin glargine) BID for diabetes mellitus. An administration history report, dated 06/29/23 - 07/29/23, did not document Novolog had been administered three times. The report did not always document the injection sites. A care plan, last reviewed 07/27/23, documented the resident had diabetes mellitus with peripheral neuropathy and to administer Levemir and Novolog per order. An administration history report,…

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 ensure competent and skilled dietary staff to meet the needs of the residents. The ''Resident Census and Conditions of Residents'' form documented 57 residents resided in the facility. The form documented three residents with feeding tubes. Findings: 1. On 08/31/22 at 12:10 p.m., the cook in the kitchen was asked to obtain the temperature of the food on the steam table. The chicken strips temperature was 85 degrees, green beans 125 degrees, and the potatoes were 102 degrees. [NAME] #2 stated the holding temperatures for food should be 160 to 165 degrees. On 08/31/22 at 12:15 p.m., the steam table on the locked unit was observed. At that time CNA #4 was asked to obtain the food temperatures of the food on the steam table. She stated she had never obtained the temperature of the food before serving it to the residents from the steam table. On 08/31/22 at 12:27 p.m., on the back hall's small dining room, CNA #5 was asked to obtain the temperature of the food on the steam table. CNA #5 stated she had never done…

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 ensure residents did not wait an extended amount of time to eat a meal while others were eating around them. The Resident Census and Conditions of Residents form documented 57 residents resided at the facility. Findings: 1. A significant change assessment, dated 06/07/22, documented Res #7 required extensive assistance with eating and had diagnoses which included vascular dementia, diabetes mellitus, anxiety, and dysphagia. A quarterly assessment, dated 08/18/22, documented Res #47 required total assistance with eating and had diagnoses which included cerebral palsy and intellectual disabilities. On 08/30/22 at 4:59 p.m., Res #7 was observed sitting at a U-shaped table with other residents who were eating. Res #7 had not been served. He had a glass of milk in front of him which was not offered to him before his food arrived. Res #47 was also sitting in the same small dining room at a table with another resident who had been served and was eating. On 08/30/22 at 5:47 p.m., Res #7 received his meal and a staff…

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 quarterly financial statements to one (#9) of one residents reviewed for personal funds. The DON identified 27 residents whose funds were maintained by the facility. Findings: A significant change assessment, dated 8/30/22, documented Res #9 was cognitively intact and the ability to make decisions about their personal belongings was very important to them. On 08/30/22 at 9:09 a.m., Res #9 stated that she did not recall receiving a statement of her personal funds. On 09/01/22, at 1:09 p.m., the administrator stated the former assistant administrator was responsible for sending quarterly statements in the past, but he had recently taken over the task. He was unable to produce any documentation Res #9 had received a quarterly statement of personal funds.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure resident rights to request, refuse, or discontinue treatment for four (#4, 7, 12, and #18) of 24 residents reviewed for advanced directives. The facility failed to ensure: a. the person who signed a DNR form was the health care proxy for Res #4, 7, and #12. b. the resident or representative was offered information on the right to formulate an advanced directive for Res #18. The Resident Census and Conditions of Residents form documented 57 residents resided in the facility. Findings: A facility policy titled Advanced Directives, revised December 2016, read in parts, .1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .6. upon admission of a resident, the social service director or designee will inquire of the resident, his/her family members and/or his or her legal…

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 residents who were discharged from skilled services with benefit days remaining a SNF ABN and NOMNC if the resident remained in the facility and a NOMNC notice if residents were discharged to home. The Beneficiary Notice - Residents discharged Within the Last Six Months form documented 24 residents had been discharged from skilled nursing services with benefit days remaining in the previous six months. Findings: 1. Res #157 was admitted to Medicare Part A skilled services on 05/08/22 and discharged from skilled services on 07/11/22. The resident was subsequently discharged to home. Res #157 was not provided a NOMNC (CMS 10123) form. 2. Res #8 was admitted to Medicare Part A skilled services on 05/07/22 and discharged from skilled services on 07/11/22. Res #8 remained in the facility. Res #8 was not provided a NOMNC (CMS 10123) form or a SNF ABN (CMS-10055) form. On 08/30/22 at 5:00 p.m., the BOM stated the facility did not use NOMNC or SNF ABN notices. She stated they provided a three day notice to residents…

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 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 (#43 and #58) of 20 residents whose care plans were reviewed. The Matrix for Providers form documented five residents had been admitted in the previous 30 days. Findings: 1. Res #43 had diagnoses which included diabetes, altered mental status, depression, and hypertension. An admission MDS assessment, documented Res #43 was moderately impaired in cognition, experienced wandering, and was independent to requiring supervision with ADLs. The assessment documented the resident received insulin, antianxiety, antidepressant, and diuretic medication. On 08/29/22 at 12:30 p.m., the resident was observed in her room sitting on a recliner. The resident stated she did not remember getting a copy of the care plan but her daughter may have. On 08/31/22 at 5:23 p.m., the MDS coordinator stated Res #43 had a base-line care plan. She stated to her knowledge,…

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.

4. Res #19's significant change assessment, dated 08/25/22, documented the resident was cognitively intact, had no rejection of care behaviors, required assistance with ADLs, had no occurrences of bathing, and was frequently incontinent of bowel and bladder. On 08/29/22 at 2:36 p.m., Res #19 stated baths were not getting done. He stated it took 45 minutes or more for them to answer the call lights. He stated he would call his wife and she would call the facility before he would get help. The resident's bathing record documented three baths in June, two in July, and one bath in August 2022. On 09/01/22 at 2:42 p.m., the DON was asked about the resident not receiving baths as scheduled. The DON stated, ''If it wasn't documented, it wasn't done. She stated the resident probably got more baths than it showed but the staff were not documenting correctly. Based on record review, observation, and record review the facility failed to provide baths/showers as scheduled for five (#19, 24, 35, 40, and #56) of five residents sampled for ADL care. The ''Resident Census and Conditions 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 who had DNR status had a physician order for the code status for three (#12, 24, and #35) of seven residents reviewed for advance directives. The ''Resident Census and Conditions of Residents'' form documented 57 residents resided in the facility. Findings: The facility's Advance Directives Policy read in part .The director of nursing services or designee will notify the attending physician of advance directive so that appropriate orders can be documented in the resident's medical record and plan of care . 1. Res #24 had diagnoses which included atrial fibrillation, diabetes mellitus, and paraplegia. The resident's medical record contained a signed DNR consent form, dated 04/09/21. A care plan, edited 04/18/22 , documented Res #24 prefers to be a DNR. A quarterly assessment, dated 07/15/22, documented the resident was severly impaired with cognition and required extensive to total care with most activities of daily living. The assessment documented the resident was on hospice. On 08/30/22 at…

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, monitor, and intervene for a non-pressure wound to a resident's skin for one (#43) of one residents reviewed for non-pressure related skin conditions. The Resident Census and Conditions of Residents form documented 57 residents resided in the facility. Findings: Res #43 had diagnoses which included diabetes, hypertension, and candidiasis. An admission MDS assessment, dated 08/09/22, documented Res #43 was moderately impaired in cognition and was independent to requiring supervision with ADLs. On 08/29/22 at 12:38 p.m., Res #48 was observed sitting on a recliner in her room. An unidentified friend of the resident was also in the room. The unidentified friend stated Res #48 had an open area on her upper left chest. The friend stated the open area had been there for several days and she had been putting ointment on the area. A nursing skin assessment, dated 08/29/22, documented Res #43's skin was intact. The assessment documented the resident had a scant amount of redness/excoriation present under 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 observation, review, and interview, the facility failed to provide physician ordered supplements for two (#23 and #46) of two residents sampled for weight loss. The Resident Census and Conditions of Residents form documented six residents with unplanned significant weight loss/gain. Findings: 1. Res #46's annual assessment, dated 05/20/22, documented the resident was moderately cognitively impaired, required assistance with ADLs, and could feed himself. The assessment documented the resident was 69 inches tall, weighed 133 pounds, had a significant weight loss, and was not on a physician prescribed weight loss program. A quarterly assessment, dated 08/18/22, documented the resident was moderately cognitively impaired, required assistance with ADLs, and could feed himself. The assessment documented the resident weighed 119 pounds, had a significant weight loss, and was not on a physician prescribed weight loss program. A physician order, dated 08/22/22, documented to provide an Ice-Cream Mighty Shake twice a day from 11:00 a.m. to 1:00 p.m. and 4:00 p.m. to 6:00 p.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 record review and interview the facility failed to ensure sufficient nursing staff to meet the needs of the residents as determined by the care plan, acuity, and physician orders. The Resident Census and Conditions of Residents form documented 57 residents resided in the facility. Findings: 1. A physician order, dated 06/17/22, documented Res #16 was to have a bath, hair and nail care three times a week and as needed. An admission MDS assessment, dated 06/24/22, documented Res #16 was moderately impaired in cognition, required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. The assessment documented Res #16 did not bathe during the assessment period. On 08/29/22 at 2:12 p.m., Res #16 was observed in her room and stated the call lights were not answered quickly and she had to wait for a long time for assistance. A review of Res #16's ADL flow sheets documented she received a bath five times out of 12 opportunities for the month of August 2022. On 09/01/22 at 1:34 p.m., the staffing coordinator stated the facility was having a difficult…

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 designate an RN to serve as the director of nursing. The Resident Census and Conditions of Residents form documented 57 residents resided in the facility. Findings: On 08/29/22 at 9:43 a.m., during the entrance conference, the administrator stated the current DON was an LPN. On 08/30/22 at 3:58 p.m., the administrator stated he was unaware the federal regulation required the DON to be an RN. He stated the current LPN/DON became the DON last January when the previous DON quit.

Based on record review and interview, the facility failed to administer medications as ordered by the physician for one (#56) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 57 residents resided in the facility. Findings: Resident #56's physician order, dated 09/29/21, documented to administer Novolog insulin per sliding scale before meals and at bedtime. A physician order, dated 04/20/22, documented to administer 10 units of Levemir insulin subcutaneously twice per day. A July 2022 MAR documented Levemir was not administered on the evening shift on 07/29/22. The MAR documented Novolog was not administered on the afternoon shift on 07/19/22 and the evening shift on 07/29/22. On 09/01/22 at 11:55 a.m., the DON reviewed Res #56's July MAR. She stated she had no explanation for the blanks on the MAR.

Based on observation, record review, and interview, the facility failed to ensure residents were free from unnecessary psychotropic medications for one (34) of five residents reviewed for unnecessary medications. The ''Resident Census and Conditions of Residents'' form documented 40 residents received psychoactive medications. Findings: Res #34 had diagnoses which included autistic disorder and major depressive disorder. A physician order, dated 04/23/21, documented Abilify (an antipsychotic medication) 5mg once a day for autistic disorder . A physician order, dated 04/23/21, documented risperidone (an antipsychotic medication) 2mg twice a day for autistic disorder. A pharmacist consult review, dated 10/06/21, documented a request for a GDR for Ability. The physician disagreed and documentated a rationale of continue to need. A pharmacist consult review, dated 01/04/22, documented a request for a GDR for Risperdal. The physician marked disagree, and documented a rationale of mental status monitored. A pharmacist consult review, dated 04/20/22, documented a request for a GDR for…

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 obseervation, record review, and interview, the facility failed to ensure food temperatures were held on the steam table at the appropriate temperature. The ''Resident Census and Conditions of Residents'' form documented 57 residents resided in the facility. The form documented three residents with feeding tubes. Findings: On 08/31/22 at 12:00 p.m., a test tray was obtained from the kitchen and walked directly to the conference room to test. At 12:01 p.m., the temperature of the chicken strips were 136 degrees F, red skin potatoes 101.7 degrees, and green beans 124.8 degrees. The chicken strips and green beans were warm and palatable. The potatoes were cool, had a overwhelming onion and vinegar taste, and was not palatable. On 08/31/22 at 12:10 p.m., the cook in the kitchen was asked to obtain the temperature of the food on the steam table. The chicken strips temperature was 85 degrees, green beans 125 degrees, and the potatoes were 102 degrees. [NAME] #2 stated the holding temperatures for food should be 160 to 165 degrees. On 08/31/22 at 12:15 p.m., the steam table on 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 observation, record review, and interview, the facility failed to ensure menus were followed for the puree meals. The ''Resident Census and Conditions of Residents'' form documented 20 residents who had a mechanically altered diet including puree and all chopped foods. The form documented three residents with feeding tubes. Findings: 1. The menu for 08/28/22 documented vegetable soup. The menu for 08/30/22 documented Salisbury steak with gravy. The menu for 08/31/22 documented for lunch they were having breaded chicken tenders, red skin potato salad, green beans, and daffodil cake. On 08/31/22 at 12:27 p.m., on the back hall's small dining room, the steam table was observed to have chicken strips, green beans, potatoes, puree #1, and puree #2. CNA #5 was asked what the puree food was. CNA #5 stated she was not sure what the puree was. There was no green puree observed on the steam table. On 08/31/22 at 12:37 p.m., the DM was asked what was served for the puree meal today. The DM stated the puree meal was Salisbury steak, vegetable soup, and ice cream. On 09/01/22 at 2:36…

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 provide food which was palatable and at a safe and appetizing temperature. The Resident Census and Conditions of Residents'' form documented 57 residents resided at the facility. Findings: 1. On 08/30/22 at 4:59 p.m., Res #7 was observed sitting with other residents who were eating. Res #7 had not been served. He had a glass of milk in front of him, but he was not offered a drink before his food arrived. Res #47 was also sitting in the same small dining room at a table with another resident who had been served. A CNA was observed plating food from a steam table in the small dining room. She plated food for residents on three halls who were eating in their rooms and for the residents who were eating in the small dining room. On 08/30/22 at 5:47 p.m., Res #7's three bowls of pureed food was served to him. The pureed bowls of food had been had been sitting on a non-heated tray throughout the time other residents were being served. At that time a staff member started to feed him. After the resident was fed a bite of pureed…

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 and interview, the facility failed to ensure food was prepared, stored, and distributed in a sanitary manner. The ''Resident Census and Conditions of Residents'' form documented 57 residents resided in the facility. The form documented three residents with feeding tubes. Findings: 1. On 08/29/22 at 11:47 a.m., DA #1 was observed in the main dining room with gloves on to touch her mask and then return to the kitchen with hands on hips standing at the steam table. DA #1 then went to the coffee pot to get coffee in same gloves, brought the coffee to the front by the steam table. The DA got a drink from a container in the kitchen, took off gloves and washed her hands. DA #1 placed new gloves on her hands and went out to the dining room to pass meals. On 08/29/22 at 11:52 a.m., DA #1 was observed to touched her mask with gloves on, pulled up her pants, and passed another meal in the dining room. DA #1 picked up a dirty plate, changed gloves, but did not perform hand hygiene before putting on new…

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 incorporate PASRR level II recommendations into the comprehensive care plan for one (#3) of one residents reviewed for PASRR level II evaluations. The DON identified eight residents who had a PASRR level II evaluation. Findings: Resident #3 had diagnoses which included cerebral palsy, severe intellectual disabilities, and recurrent depressive disorders. A PASRR level II, completed 12/05/19, documented Res #3 required monitoring for eye health and recommended activities included taking the resident outside when weather permitted. A care plan, reviewed 03/01/22, did not include monitoring for eye health or the recommended activity documented on the PASRR level II. A quarterly resident assessment, dated 08/25/22, documented Res #3 was severely cognitively impaired, had highly impaired vision, and required extensive to total assistance with all ADL's. On 08/30/22, at 3:03 p.m., the MDS Coordinator stated she recorded which residents required a PASRR on the care plan, but she had not seen the PASRR recommendations for Res #3.…

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 observation, review, and interview, the facility failed to ensure medications were administered by accepted clinical practice to decrease the potential for feeding tube complications. The Resident Census and Conditions of Residents documented three residents required tube feedings. Findings: Resident #3 had diagnoses which included cerebral palsy, severe intellectual disabilities, and gastrostomy status. The facility policy, Administering Medications through and Enteral Tube revised November 2018, documented to administer each medication separately and flush between medications, and verify placement of feeding tube before giving medications. A physician order, dated 04/21/15, documented to flush PEG tube with 30 cc of water before and after giving medications. A physician order, dated 05/04/15, documented to check patency and placement of PEG tube before and after each feeding or medication administration. A physician order, dated 11/09/16, documented to check for residual before administering medications. A care plan, revised 03/01/22, documented interventions…

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.