Sequoyah Pointe Skilled Nursing and Therapy

Inspectors wroteOn 05/13/25, a past noncompliance situation was determined to exist related to the facility's failure to provide supervision to protect residents. An incident report, dated 05/02/25, showed Resident #1 had left the facility without staff knowledge and was found by local police in a commercial establishment's parking lot approximately 400 feet from the facility. Resident #1 was returned to the facility within 30 minutes of their departure and was transferred to a secured facility two days later. Based on observation, record review, and interview the facility failed to ensure a resident with a history of elopement did not elope from the facility for 1 (#1) of 3 sampled residents reviewed for accident hazards. Corp. Nurse Consult. #1 reported five residents wandered at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a call light was in reach for one (#35) of 24 sampled residents observed for call lights. The administrator identified 54 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan within 14 days of admission for one (#24) of 14 sampled residents whose care plans were reviewed. The DON identified 54 residents resided at the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure heel lift boots were in place as ordered for one (#36) of two sampled residents reviewed for pressure ulcer care. The administrator identified seven residents had orders for heel lift boots.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The administrator reported 58 residents resided in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure the facility maintained a clean, odor-free, and homelike environment. The CMS 671 form, dated 10/26/23, documented 58 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for two (#8 and #43) of five sampled residents reviewed for bathing. The CMS 671 form, dated 10/26/23, documented 58 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to document and retain daily staffing information for the past 18 months. The CMS 671 form, dated 10/26/23, documented a census of 58 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who was physically restrained was assessed, monitored, and the restraint was used to treat a medical symptom for one (#16) of one sampled resident who was reviewed for seat belt usage. The DON identified one resident who used a seat belt.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#8) of one sampled residents reviewed for PASRR. The administrator reported 37 residents had mental health diagnoses.

Inspectors wroteBased on observation, record review, and interview, the facility failed to update a comprehensive care plan for one (#20) of one sampled resident who was reviewed for a PEG tube. The DON reported there was one resident with a PEG tube.

Inspectors wroteBased on record review and interview, the facility failed to accurately assess for the presence of a PASRR level II for three (#3, 35 and #49) of 16 residents whose assessments were reviewed. The ''Resident Census and Conditions of Residents'' form documented 51 residents lived in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident newly diagnosed with a serious mental illness was referred for a PASRR level II evaluation and failed to incorporate PASRR level II recommendations into a resident care plan for three (#3, 48, and #29) of three residents reviewed for PASRR. The administrator reported 14 residents with PASRR Level II evaluations lived in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure dependent residents were provided assistance with bathing/showers, grooming, and incontinent care for four (#35, 38, 103, and #104) of five sampled residents reviewed for staff assistance with ADLs. The Resident Census and Conditions of Residents report documented 21 residents required assistance with bathing and 25 residents are occasionally or frequently incontinent of bladder.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide services to prevent urinary tract infections for two (#37 and #102) of two residents reviewed for indwelling urinary catheters. The Resident Census and Conditions of Residents report documented two residents who required indwelling urinary catheters.

Inspectors wrote5. Resident #37 had diagnoses including neuromuscular dysfunction of bladder, and urinary tract infection. A physician order dated, 10/28/21, documented to perform catheter care every shift and as needed with soap and water or disposable wipes. A review of the treatment administration record did not document catheter care had been performed on 04/02/22, 04/03/22, 04/07/22, 04/09/22, 04/18/22, 05/13/22, and 05/21/22. A physician order, dated 10/28/2021, documented to change suprapubic catheter drainage bag on the 1st and 15th and as needed. A review of the treatment administration record documented the suprapubic catheter drainage bags had not been changed on 04/01/2022, and 05/15/2022. A physician order, dated 03/02/22, documented to collect vital signs every shift. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure nurse aids who had been employed greater than one year completed a performance review. The administrator reported the facility employed four CNAs who had worked at the facility for greater than one year.

Inspectors wroteBased on record review, observation, and interview, the facility failed provide pharmaceutical services including dispensing per physician order and failed to ensure an accurate accounting of controlled drugs for four, (#3, 33, 37, and #50) of five residents reviewed for unnecessary medication. The Resident Census and Conditions of Residents form documented 51 residents who resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to obtain physician ordered PT/INR labs for one (#48) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 51 residents resided in the facility.

Inspectors wroteBased on observation' and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The Census and Conditions of Residents form documented 51 residents lived in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to implement CDC guidelines for infection control procedures to prevent the transmission of COVID-19 and/or other infections for the residents who resided in the facility. The facility failed to administer medications in a sanitary manner, properly use hand hygiene when assisting residents with eating, and not eat in the medication rooms of the facility. The Resident Census and Conditions of Residents report documented 51 residents lived in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the attending physician responded to medication regimen reviews for one (#33) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 51 residents resided in the facility.