A list of the most recent deficiencies for Sequoyah East Nursing Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-07 | 2024-02-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-07 | 2024-02-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-12-07 | 2024-02-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-12-07 | 2024-02-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-07 | 2024-02-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-07 | 2024-02-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-07 | 2024-02-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-07 | 2024-02-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-07 | 2024-02-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-07 | 2024-02-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-07 | 2024-02-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-07 | 2024-02-02 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2023-12-07 | 2024-02-02 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-12-07 | 2024-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-02-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-07 | 2024-02-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-09 | 2023-12-05 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-09 | 2023-12-05 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-24 | 2023-03-07 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-21 | 2022-12-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-21 | 2022-12-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-21 | 2022-12-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-10-21 | 2022-12-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-21 | 2022-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-21 | 2022-12-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-21 | 2022-12-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-21 | 2022-12-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-21 | 2022-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-19 | 2022-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-19 | 2022-12-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-15 | 2022-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-08 | 2021-12-15 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-10-08 | 2021-12-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-08 | 2021-12-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-08 | 2021-12-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-08 | 2021-12-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-08 | 2021-12-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-08 | 2021-12-15 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-10-08 | 2021-12-15 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-10-08 | 2021-12-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-08 | 2021-12-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-08 | 2021-12-15 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-10-08 | 2021-12-15 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-10-08 | 2021-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-08 | 2021-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-08 | 2021-12-15 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-08 | 2021-12-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-08 | 2021-12-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-08 | 2021-12-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-08 | 2021-12-15 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-08 | 2021-12-15 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-08 | 2021-12-15 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-08 | 2021-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-08 | 2021-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2021-12-15 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-10-08 | 2021-12-15 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-05 | 2021-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-08 | 2021-11-05 | N |
