The Vardell Report.Sequoyah East Nursing Center, LLC

Across 8 inspections from October 2022 to July 2025, state surveyors documented 54 findings at Sequoyah East Nursing Center, LLC; 54 have a recorded correction; CMS lists 6 enforcement actions in the window.

Inspections

8

2022–2025, complaint and standard

Findings

54

Deficiencies cited by state inspectors

Corrected

54

Of 54 findings, with a recorded correction date

Penalties

6

5 fines; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 22025

   Complaint investigation

   2 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 22, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Aug 22, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Apr 162025

   Standard health inspection

   12 findings

   • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected May 30, 2025
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected May 30, 2025
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected May 30, 2025
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected May 30, 2025
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected May 30, 2025
   • F758Implement 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.Level ENo actual harm, potential for moreCorrected May 30, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected May 30, 2025
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected May 30, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 30, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 30, 2025
   • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected May 30, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected May 30, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Apr 102024

   Complaint investigation

   1 finding

   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 27, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Mar 72024

   Complaint investigation

   9 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 11, 2024
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Apr 18, 2024
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Apr 19, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Apr 11, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 4, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 19, 2024
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Apr 4, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Dec 72023

   Standard health inspection

   16 findings

   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level FNo actual harm, potential for moreCorrected Feb 2, 2024
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level ENo actual harm, potential for moreCorrected Feb 2, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Feb 2, 2024
   • F758Implement 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.Level ENo actual harm, potential for moreCorrected Feb 2, 2024
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Feb 2, 2024
   • F772Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.Level ENo actual harm, potential for moreCorrected Feb 2, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 2, 2024
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Feb 2, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 2, 2024
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Feb 2, 2024
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Feb 2, 2024
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Feb 2, 2024
   • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 2, 2024
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Feb 2, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Feb 2, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Feb 2, 2024

   Enforcement Action

   Civil money penalty, $13,762 imposed December 11, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 7, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $14,814 imposed January 22, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 7, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $4,938 imposed February 12, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 7, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $4,938 imposed February 20, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 7, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $50,381 imposed March 7, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 7, 2023, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed March 7, 2024. Status: Closed, May 27, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 7, 2023, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Oct 92023

   Complaint investigation

   2 findings

   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level FNo actual harm, potential for moreCorrected Dec 5, 2023
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Dec 5, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Oct 42023

   Complaint investigation

   2 findings

   The same visit included an infection control inspection.

   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Nov 17, 2023
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Nov 17, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Oct 212022

   Standard health inspection

   10 findings

   • F578Honor 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.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Dec 1, 2022

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in October 2022, March 2024 and April 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F689 across all 8 inspections, oldest to newest
2. 2

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in October 2023, December 2023 and March 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F880 across all 8 inspections, oldest to newest
3. 3

   Treatment Choices and Advance Directives, Cited in Two Inspections

   Inspectors cited F578 in October 2022 and October 2023. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F578 across all 8 inspections, oldest to newest
4. 4

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in March 2024 and July 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F600 across all 8 inspections, oldest to newest
5. 5

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in March 2024 and July 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F610 across all 8 inspections, oldest to newest
6. 6

   Citation F637, Cited in Two Inspections

   Inspectors cited F637 in December 2023 and April 2025. The agency describes it this way: Assess the resident when there is a significant change in condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F637 across all 8 inspections, oldest to newest
7. 7

   The First 48 Hours, Cited in Two Inspections

   Inspectors cited F655 in October 2022 and April 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F655 across all 8 inspections, oldest to newest
8. 8

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in October 2022 and April 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F656 across all 8 inspections, oldest to newest
9. 9

   Help With Daily Living, Cited in Two Inspections

   Inspectors cited F677 in October 2023 and March 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2223232324242525F677 across all 8 inspections, oldest to newest
10. 10

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in December 2023 and April 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2223232324242525F758 across all 8 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in three inspections, most seriously at level G.

2. 02

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level E.

3. 03

   How are a resident’s advance directive and treatment wishes recorded and shared with every shift?

   Treatment Choices and Advance Directives: cited in two inspections, most seriously at level E.

4. 04

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.

5. 05

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in two inspections, most seriously at level E.

6. 06

   What changed after F637 was cited, and how do you check it now?

   Citation F637: cited in two inspections, most seriously at level D.

7. 07

   What happens in the first 48 hours after admission, and who writes the first care plan?

   The First 48 Hours: cited in two inspections, most seriously at level E.

8. 08

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level D.

9. 09

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in two inspections, most seriously at level E.

10. 10

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level E.

11. 11

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

12. 12

    What led to the 2024 fine, and has it been paid?

    A $50,381 civil money penalty was imposed March 7, 2024. CMS publishes the fine, not whether it has been paid. The record holds six enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oklahoma state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Oct 21, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Oct 4, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Oct 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Dec 7, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Mar 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Apr 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Apr 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oklahoma state survey agency

  Inspection Jul 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 375394

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.