Sequoyah Manor, LLC

In the surveyor’s words

From the most serious findings on record at Sequoyah Manor, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 19, 2024

  On 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. […]

• Actual harm, isolatedF600Jan 14, 2026

  Based 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.Findings: 1.An OSDH incident report form, dated 09/12/25, showed CNA #7 witnessed Resident #12 hit Resident #8 on the top of their head. The report showed Resident #8 was assessed and found to be free of injury. The report showed Resident #12 was placed on 1:1 until sent to ER psych evaluation. The report showed Resident #12 had a BIMS score of 1 indicating they were severely cognitively impaired. […]

• Actual harm, isolatedF689Mar 18, 2025

  Based 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. Findings: Resident #1 had diagnoses which included dementia. A quarterly assessment, dated 01/08/25, showed Resident #1 had a BIMS score (a test for cognitive function) of 12, which was indicative of a moderate impairment for daily decision making and required set-up assistance with eating and drinking. A nurse note, dated 03/09/25 at 10:30 a.m., showed Resident #1 had spilled coffee on themselves. […]

• No harm, potential for more than minimal, widespreadF812Sep 1, 2023

  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. […]

• No harm, potential for more than minimal, widespreadF802Sep 1, 2022

  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. Cook #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. […]