Sequoyah Manor, LLC

Inspectors wroteBased on record review and interview, the facility failed to protect residents from abuse for 2 (#8 and #10) of 5 sampled residents reviewed for abuse. The administrator identified 77 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide supervision to prevent burns from hot liquids for 1 (#1) of 3 sampled residents reviewed for accident hazards. This resulted in actual harm when Resident #1 received a second degree burn. ADON #1 reported 65 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan related to assisting a resident with hot liquids for 1 (#1) of 3 sampled residents whose care plans were reviewed. ADON #1 reported 65 residents resided in the facility.

Inspectors wroteOn 12/16/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure chemicals were secured away from wandering residents on a locked dedicated memory care unit. On 12/16/24 at 10:15 a.m., an unlocked closet (with gauze stuffed in the door latch not allowing the door to shut) had bug spray (Spectracide Bug Stop Home Barrier), a can of paint, shaving lotion, and other personal care items documenting keep out of reach of children. Three residents were observed wandering in the hall aimlessly. At 10:33 a.m., CNA #1 assigned to the locked memory unit stated the key to the door had been lost over the weekend, so the gauze was placed to allow access. CNA #1 stated there were nine residents on the unit and five that wandered independently. At 10:42 a.m., the DON stated the door should be locked and was unaware there was a problem with the lock. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a copy of the baseline care plan had been provided to the resident and/or resident representative for three (#2, 15, and #29) of 19 sampled residents whose baseline care plans were reviewed. The DON identified 64 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error of less than five percent order for two (#5 and #34) of 27 residents who were reviewed for medication administration. The medication error rate was 7.41%. The DON identified 64 residents who received medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prepare and serve food in a sanitary manner. The DM identified the kitchen prepared meals for 64 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. proper PPE was worn during catheter care for one (#15) of three sampled residents who were reviewed for catheter care; b. hand sanitation was completed during catheter care for one (#4 ) of three sampled residents who were reviewed for catheter care; and c. hand sanitation was completed during medication administration for four (#5, 34, 51, and #60) of 27 sampled residents who were reviewed for medication administration. The DON identified 11 residents who had catheters, 13 residents who were on enhanced barrier precautions, and 64 residents who received medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dignity with an indwelling urinary catheter for one (#15) of three sampled residents reviewed for indwelling urinary catheters. The DON identified 11 residents who had indwelling urinary catheters.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurate for one (#37) of 16 sampled residents whose assessments were reviewed. The DON identified 64 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a comprehensive care plan had been developed for one (#15) of 19 sampled residents whose care plans were reviewed. The DON identified 64 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure range of motion services were provided to one (#15) of three sampled residents who were reviewed for limited range of motion. The MDS coordinator identified 18 residents who had limited range of motion.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control was maintained for indwelling urinary catheters, failed to secure indwelling urinary catheters, and failed to document catheter care in accordance with the care plan for one (#15) of three sampled residents who were reviewed for indwelling urinary catheters. The DON identified 11 residents who had indwelling urinary catheters.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview, the facility failed to follow the menus for the residents. The DM identified the kitchen prepared meals for 64 residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote4. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote4. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.