Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sequoyah East Nursing Center, Llc during CMS and state inspections, most recent first.
A resident with a documented history of assaulting staff was not consistently monitored or managed, resulting in the resident physically assaulting another resident with moderate cognitive impairment in the dining area. Staff interviews revealed a lack of ongoing behavioral monitoring or intervention, despite the facility's policy to protect all residents from abuse.
A resident was physically assaulted by another resident in the dining area, and the facility's investigation was limited to interviewing only the two residents involved and staff present at the time. No other residents were interviewed to determine if further harm had occurred, contrary to facility policy requiring comprehensive abuse investigations.
The facility failed to protect resident medical records from unauthorized access by former employees. An LPN accessed the EHR system after resigning, viewing multiple areas of a resident's documentation. Another LPN accessed the system after leaving employment, viewing several pages of records, including residents' MARs. The facility's EHR system allowed offsite access, which was not regularly monitored for unauthorized use.
The facility failed to provide adequate supervision to prevent falls for two residents, leading to multiple falls and injuries. Despite having care plans, the plans were not updated, resulting in repeated falls and significant injuries, including a severe head injury that led to a resident's death.
The facility failed to implement its Background Check Policy, resulting in incomplete and undocumented background checks for several employees. The business office manager admitted to not documenting reference or employment history checks and completing registry checks after the first day of employment. A review of employment records confirmed these deficiencies.
The facility staff failed to report allegations of abuse to their administrator within the required timeframe for four residents. Incidents involving residents with dementia, anxiety, heart failure, vascular dementia, cerebrovascular disease, neurocognitive disorder, and psychosis were reported late, contrary to the facility's abuse reporting policy.
The facility failed to revise care plans for falls for three residents, despite multiple falls and injuries. The MDS coordinator and DON acknowledged the care plans had not been updated, and the DON admitted to not attending care plan meetings or being aware of their responsibility to do so.
The facility failed to ensure showers were given as ordered for two residents. One resident with hypertension and emphysema received two showers and refused two, but missed nine other scheduled showers. Another resident with mild intellectual disabilities and anxiety received two showers and refused three, but missed eight other scheduled showers. CNA confirmed the discrepancies, and the administrator acknowledged responsibility.
A facility failed to ensure a CNA used gloves while providing personal care to two residents with severely impaired cognition, leading to a breach in infection prevention protocols. Multiple staff members reported witnessing the CNA's actions, and the DON confirmed the CNA did not follow the facility's standards, resulting in their termination.
A facility failed to notify a resident's representative of a transfer to another facility for therapy. The resident had mild intellectual disabilities and a fractured left femur, requiring moderate assistance. The administrator assumed the receiving facility had contacted the representative, which was not documented in the resident's record.
A CNA mentally abused a resident with dementia and psychosis by making distressing comments about Indians harming children. Despite attempts by other staff to deescalate the situation, the CNA continued the psychological torment, causing the resident significant distress. The incident was reported and the CNA was subsequently terminated.
A facility failed to prevent a staff member from working outside their scope of practice by attempting a blood draw on a resident with vascular dementia and cerebrovascular disease. The ADON observed but did not stop the SSD, who was no longer certified as a phlebotomist, from performing the procedure. The DON later confirmed that the ADON should have intervened.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident with a known history of assaultive behavior. Documentation in the medical record showed that one resident had multiple prior incidents of physically assaulting staff, including hitting, scratching, and beating staff members with objects. Despite these repeated behaviors, there was no consistent monitoring or behavioral intervention plan in place for this resident, except for a brief four-day period in March. Staff interviews confirmed that there was no ongoing order to monitor the resident's behavior, and monitoring was only done if an incident was observed and documented in a progress note. On one occasion, the resident with a history of assaultive behavior kicked another resident in the lower left leg while both were in the dining area. The assaulted resident had a moderate cognitive impairment, as indicated by a recent assessment. Staff were unaware of any prior incidents of this resident harming other residents before this event, and there was no evidence of proactive measures to prevent such incidents. The facility's policy committed to protecting residents from abuse by anyone, including other residents, but this was not effectively implemented in this case.
Failure to Thoroughly Investigate Resident-to-Resident Assault
Penalty
Summary
The facility failed to conduct a thorough investigation following a resident-to-resident physical assault. According to progress notes, one resident was kicked in the leg by another resident while in the dining area. The facility's investigative documentation showed that only the two residents involved and staff on duty at the time were interviewed. There was no evidence that other residents were interviewed to determine if the resident who committed the assault had harmed anyone else. The Director of Nursing confirmed that they had not considered interviewing additional residents as part of the investigation, despite facility policy requiring all reports of abuse to be thoroughly and promptly investigated.
Unauthorized Access to EHR by Former Employees
Penalty
Summary
The facility failed to safeguard resident medical records against unauthorized use, as evidenced by two incidents involving former employees accessing the electronic health record (EHR) system after their employment had ended. The first incident involved an LPN who resigned on 02/27/24 but accessed the EHR system on 03/01/24, viewing multiple areas of a resident's documentation. The administrator was aware that the LPN was in the facility on the day of resignation but assumed they were there to speak with a survey team. The LPN's access to the EHR system was only terminated after their resignation. The second incident involved another LPN who left the facility on 03/21/24 but accessed the EHR system on 04/01/24 and 04/02/24, viewing several pages of the facility's records, including multiple residents' medication administration records (MARs). The administrator acknowledged that the EHR system allowed offsite access, which was not regularly monitored for unauthorized use unless there was a suspicion or complaint. This lack of regular checks contributed to the unauthorized access by the former employees.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents, leading to multiple incidents of falls and injuries. Resident #1, who had diagnoses including dementia, anxiety, and heart failure, experienced eight falls over a period of time. Despite having a care plan with 11 interventions, the resident continued to fall, resulting in injuries such as skin tears and a significant head injury that led to hospitalization. The care plan for Resident #1 had not been updated since July 2022, and the resident ultimately died after a severe fall that caused a right orbital floor fracture and significant swelling and laceration to the forehead, eye, and cheek. The facility's failure to update the care plan and implement effective interventions contributed to the resident's repeated falls and injuries. Resident #5, who had diagnoses including hypertension and emphysema, also experienced multiple falls. The care plan for Resident #5 had not been updated with new fall interventions since July 2022, despite the resident having several falls. The MDS coordinator and the DON acknowledged that the care plans were not updated regularly and did not reflect the residents' current conditions and treatments. The facility's inadequate care planning and failure to follow policies and procedures for fall prevention contributed to the residents' falls and injuries.
Failure to Implement Background Check Policy
Penalty
Summary
The facility failed to implement its policy and procedures to ensure that applicants' employment history and references were checked, and that registry checks were completed prior to employment. The facility's Background Check Policy mandates that background checks, including prior employment verification, reference checks, license verification, and criminal background checks, be completed before the first day of assigned work. However, the business office manager admitted that they did not typically document checking references or employment history and were trained to complete registry checks after the first day of employment. This was confirmed during a review of employment records, which revealed that none of the 19 records reviewed had documentation of verified previous employment or contacted references, and one record lacked documentation of registry checks. Additionally, seven records did not have OSDH background check letters, and one CNA's registry checks were completed two days after their first day of employment. The administrator confirmed that the business office manager was responsible for completing and documenting employment history checks and reference checks, and ensuring that registry checks were completed prior to employment. Despite this responsibility, the business office manager failed to adhere to the facility's policy, resulting in incomplete and undocumented background checks for several employees. This lapse in procedure was identified during a survey, highlighting the facility's failure to ensure the safety and compliance of its hiring practices.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility staff failed to report allegations of abuse to their administrator within the timeframe indicated in state regulations for four residents. The facility's abuse reporting and investigation policy, dated September 2022, required that suspicions of abuse, neglect, exploitation, misappropriation of resident property, or injury of an unknown source be reported immediately to the administrator and other officials according to state law. However, the incidents involving Residents #1, #2, #3, and #7 were not reported within the required timeframe. For instance, the incident involving Resident #1, who had diagnoses including dementia, anxiety, and heart failure, was reported to the social services director the day after the alleged incident. Similarly, the incidents involving Residents #2 and #3, both with severely impaired cognition, were reported to local law enforcement but not immediately to the administrator. The incident involving Resident #7, who had dementia and psychosis, was reported six days after it occurred. The administrator confirmed that they were informed of the incidents involving Residents #1, #2, #3, and #7 well after the required reporting timeframe. Specifically, the administrator learned about the incident involving Resident #1 the day after it occurred, and the incident involving Resident #7 six days after it occurred. The Director of Nursing (DON) acknowledged that the staff had not been following the policy regarding the timely reporting of abuse allegations. This failure to adhere to the facility's abuse reporting policy resulted in a deficiency in meeting state regulations for reporting allegations of abuse within the specified timeframe.
Failure to Revise Care Plans for Falls
Penalty
Summary
The facility failed to revise resident care plans related to falls for three of seven sampled residents reviewed for abuse and neglect. Resident #1, who had diagnoses including dementia, anxiety, and heart failure, experienced eight falls between specific dates, three of which resulted in injuries such as skin tears and a fracture. Despite these incidents, the care plan for Resident #1 had not been updated since July 2022. The MDS coordinator and DON acknowledged that the care plan had not been revised to reflect the resident's condition and falls, and the DON admitted to not attending care plan meetings or being aware of their responsibility to do so. Resident #5, with diagnoses including hypertension and emphysema, had multiple falls documented, yet no new fall interventions had been added to their care plan since a specific date. Similarly, Resident #6, who had mild intellectual disabilities and anxiety, experienced falls, including one resulting in a broken femur, but their care plan had not been updated with new interventions since a specific date. The MDS coordinator admitted that interventions should have been added but were not, and the DON described the facility's care planning as inadequate, with the MDS coordinator not following the care planning policy and procedures.
Failure to Administer Showers as Ordered
Penalty
Summary
The facility failed to ensure showers were given as ordered for two residents. Resident #5, who had diagnoses including hypertension and emphysema, was documented as severely impaired for daily decision making and required moderate assistance with ADLs. In February 2024, Resident #5 received two showers and refused two, but on nine other scheduled shower days, either did not receive a shower or it was not documented. Resident #6, with diagnoses including mild intellectual disabilities and anxiety, was moderately impaired for daily decision making and required partial assistance. In February 2024, Resident #6 received two showers and refused three, but on eight other scheduled shower days, either did not receive a shower or it was not documented. CNA #8 confirmed the discrepancies in shower documentation. The administrator acknowledged that the charge nurse should ensure showers are administered as ordered, but ultimately the DON and administrator were responsible.
Failure to Use Gloves During Resident Care
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) used gloves while providing personal care to residents, leading to a breach in infection prevention and control protocols. Specifically, CNA #1 was observed using their bare hands to check the dryness of Resident #3's brief and to change the brief of Resident #2, making direct contact with the resident's bare buttocks. These actions were documented in handwritten statements by other CNAs and confirmed through interviews with staff members. Both residents involved had severely impaired cognition, with Resident #2 diagnosed with vascular dementia and cerebrovascular disease, and Resident #3 diagnosed with neurocognitive disorder with Lewy bodies and chronic obstructive pulmonary disease. Multiple staff members, including CNAs #5, #6, and #7, reported witnessing CNA #1's failure to don gloves during personal care tasks. The Director of Nursing (DON) acknowledged that nursing staff are aware of the requirement to wear gloves during resident care and confirmed that CNA #1 did not adhere to the facility's standards of practice and policy. As a result, CNA #1's employment was terminated. The facility's policy on standard precautions, dated September 2022, mandates the use of gloves in all resident care situations to prevent the spread of infectious diseases.
Failure to Notify Resident's Representative of Transfer
Penalty
Summary
The facility failed to ensure the resident's representative was notified of a transfer for one resident who was reviewed for notification of change. The resident had diagnoses including mild intellectual disabilities and a fractured left femur and was moderately impaired for daily decision-making, requiring moderate assistance from staff. A nurse's note documented that the resident had been transferred to another facility for therapy, but a review of the resident's record did not show that the resident's representative had been notified of the transfer. The administrator stated that they did not notify the resident's representative because they thought the facility the resident transferred to had contacted them. The administrator later acknowledged that the resident's representative should be notified and that it should be documented in the resident's chart.
Mental Abuse by CNA
Penalty
Summary
The facility failed to prevent a certified nurse aide (CNA) from mentally abusing a resident diagnosed with dementia and psychosis. The resident, who had moderately impaired cognition, made delusional statements about Indians harming children. On one occasion, CNA #13 antagonized the resident by asking if they were going to eat her babies, which caused the resident significant distress. Despite attempts by other staff members to deescalate the situation, CNA #13 continued to torment the resident, leading to the resident crying and becoming more agitated. Two other CNAs witnessed the incident and reported that CNA #13 made further distressing comments, such as claiming to be an Indian and suggesting that the resident's babies tasted good. The resident's distress escalated, and CNA #13 continued the psychological torment despite being asked to leave. The incident was reported to the facility administrator several days later, who then conducted an investigation and terminated CNA #13's employment.
Unqualified Staff Member Attempts Blood Draw
Penalty
Summary
The facility failed to prevent a licensed nurse from allowing a staff member to work outside their scope of practice by attempting a blood draw on a resident. The incident involved a resident with vascular dementia and cerebrovascular disease. The Assistant Director of Nursing (ADON) observed the Social Services Director (SSD) attempting to collect a blood sample from the resident using a phlebotomy set. Despite not giving the SSD directions to perform the blood draw, the ADON did not stop the SSD from proceeding. The SSD, who was no longer certified as a phlebotomist and had not been hired for that role, attempted the blood draw but was unsuccessful. The ADON then decided not to make another attempt as the resident required hydration. The Licensed Practical Nurse (LPN) also witnessed the SSD performing the blood draw with the ADON present in the room but did not intervene to stop the procedure. The SSD admitted to attempting the blood draw after the contract phlebotomist was unable to obtain a sample and the LPN requested assistance from the ADON. The SSD mentioned their past certification as a phlebotomist during their hiring process but had declined to perform such tasks at the facility. The Director of Nursing (DON) later stated that the ADON should have stopped the SSD from attempting the blood draw, as it was against the facility's policy regarding venipuncture. The facility's policy on obtaining blood specimens clearly outlines that only qualified personnel should perform such procedures to ensure safe and aseptic sampling of the resident's blood.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Health Services | 5.2 mi | ★★★★★ | 6 | 0 |
| The Blossoms At Fort Smith Rehab & Nursing Center | 6.5 mi | ★★★★★ | 9 | 0 |
| Legacy Health And Rehabilitation Center | 6.8 mi | ★★★★★ | 0 | 0 |
| Chapel Ridge Health And Rehab | 7.1 mi | ★★★★★ | 0 | 0 |
| Covington Court Health And Rehabilitation Center | 7.5 mi | ★★★★★ | 5 | 0 |
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