Sequoyah Pointe Living Center

In the surveyor’s words

From the most serious findings on record at Sequoyah Pointe Living Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 10, 2021

  Based on observation, interview, and record review, it was determined the facility failed to prevent accident hazards for one (#6) of three sampled residents reviewed for falls. On 03/19/21 one staff member was transferring resident #6 with the use of a Hoyer lift. The resident fell and broke her hip. The facility failed to ensure proper technique was used to transfer a resident by Hoyer lift. The facility identified 29 residents had fallen in the past six months and 13 residents required the use of a Hoyer lift. Findings: A facility policy for using a portable lifting machine, revised December 2013, documented two nursing assistants were required to perform this procedure. […]

• No harm, potential for more than minimal, patternF804Apr 15, 2025

  Based on observation and interview, the facility failed to ensure food served from the kitchen was palatable and served at an appetizing temperature. The DON identified 36 residents who ate from the kitchen. Findings: On 04/08/25 at 12:40 p.m., Residents #10 and #31 were observed sitting together in the dining room with their food uneaten. On 04/08/25 at 1:32 p.m., a test tray was delivered. The food was observed to not be hot, the cake was dry and crumbling off the fork, and the steak finger breading was observed to be white in color and to touch was gooey and not thoroughly cooked. On 04/08/25 at 11:10 a.m., Resident #9 stated the food was lousy, everything from seasoning to how it was prepared. […]

• No harm, potential for more than minimal, patternF600Jul 31, 2024

  Based on record review and interview, the facility failed to ensure the residents' right to be free of abuse for two (#1 and #2) of three residents reviewed for abuse. The facility's Resident List Report documented 44 residents lived in the facility. Findings: A resident abuse, neglect, exploitation, and misappropriation prevention program policy, revised April 2021, documented the policy's objectives were: - to protect residents from abuse by anyone, including facility staff and other residents; - to establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems; and -to protect residents from any further harm during the investigations. 1. […]

• No harm, potential for more than minimal, patternF657Jun 7, 2024

  Based on record review and interview, the facility failed to have the participation of the resident or the resident representative in the development of the resident's person centered care plan for three (#1, 2, and #3) of three residents whose care plans were reviewed. The facility's Resident List Report documented 46 residents. Findings: 1. Resident #1 was admitted [DATE] and had diagnoses which included aphasia and psychotic disorder with delusions. On 06/03/24 at 4:25 p.m., a family member was interviewed and stated they were not notified of or offered an opportunity to participate in the resident's care plan meetings. On 06/04/24, the resident's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF677Dec 11, 2023

  Based on record review and interview, the facility failed to ensure showers were provided for two (#7 and #11) of three residents reviewed for bathing. The administrator reported the census was 42. Findings: 1. Resident #7 had diagnoses which included chronic obstructive pulmonary disease and anemia. An admission assessment, dated 06/02/23, documented Resident #7 was moderately impaired in cognition and required assistance with bathing. A review of Resident #7's shower documentation sheets did not document the resident had been offered a shower between 10/2/23 and 10/26/23 or between 11/10/23 and 12/07/23. On 10/06/23 at 10:30 a.m., Resident #7 stated if a shower aide was not working, they usually did not get a shower. 2. […]