Sequoyah East Nursing Center, LLC

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was not physically assaulted by another resident with a history of assaulting others for 1 (#1) of 6 sampled residents reviewed for abuse. The ADON reported 46 residents resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough investigation of a resident-to-resident physical assault for 1 (#1) of 6 sampled residents reviewed for abuse. The ADON reported 46 residents resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS within the mandated timeframe. The administrator stated there were 51 residents residing at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dignity was maintained when residents were assisted with meals for 3 (#31, 28, and #23) of 8 residents observed during dining. The MDS coordinator identified six residents who were dependent on staff for eating.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was provided with a written notice of transfer prior to being transferred to an acute care hospital for 1 (#40) of 2 sampled residents reviewed for discharges. The DON stated 49 residents had transferred to a hospital from [DATE] through 04/14/25.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurately coded for 1 (#26) of 17 sampled residents whose assessments were reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was completed for 2 (#22 and #45) of 9 sampled residents whose baseline care plans were reviewed. The DON identified 51 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure an antipsychotic medication had: a. an appropriate diagnosis for 1 (#17); and b. side effect monitoring was in place for 2 (#17 and #22) of 5 sampled residents reviewed for unnecessary medications. The DON reported 42 residents received psychotropic medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who wanted a pneumococcal vaccination received the vaccination for 2 (#3 and #14) of 5 sampled residents reviewed for immunizations. The DON stated 21 residents had been admitted to the facility in the past six months and had been assessed for the need and desire to receive pneumococcal immunizations.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change assessment for 1 (#36) of 1 resident reviewed for hospice. The DON reported 51 residents resided in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview, the facility failed to provide supervision to prevent falls for two (#1 and #5) of seven sampled residents reviewed for abuse. A facility resident roster, dated [DATE], documented 45 residents resided in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote8. 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.