Sequoyah Manor, LLC
615 East Redwood · Sallisaw, OK · 74955 · 9187754881
162 certified beds For profit - Limited Liability company
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 2 · $33,270 |
Inspection citations (62 in the current record)
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Actual harm · G January 14, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Past Non-Compliance · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G March 18, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 17, 2025 · Quality of Life and Care
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Potential for harm · D March 18, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 17, 2025 · Resident Assessment and Care Planning
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Immediate jeopardy · K December 19, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 24, 2025 · Quality of Life and Care
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Potential for harm · D December 19, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 24, 2025 · Resident Rights
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Potential for harm · D December 19, 2024
Ensure each resident receives an accurate assessment.
Corrected January 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · E December 19, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 19, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 19, 2024
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected January 24, 2025 · Quality of Life and Care
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Potential for harm · D December 19, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected January 24, 2025 · Quality of Life and Care
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Potential for harm · D December 19, 2024
Try 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.
Corrected January 24, 2025 · Quality of Life and Care
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Potential for harm · E December 19, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected January 24, 2025 · Pharmacy Service
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Potential for harm · D December 19, 2024
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected January 24, 2025 · Nutrition and Dietary
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Potential for harm · E December 19, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 24, 2025 · Nutrition and Dietary
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Potential for harm · E December 19, 2024
Provide and implement an infection prevention and control program.
Corrected January 24, 2025 · Infection Control
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Potential for harm · D December 19, 2024
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected January 24, 2025 · Environmental
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Potential for harm · D November 13, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 19, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 11, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 25, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E September 11, 2024 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected October 25, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 11, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 25, 2024 · Resident Assessment and Care Planning
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Potential for harm · D September 1, 2023
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected October 31, 2023 · Resident Rights
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Potential for harm · E September 1, 2023
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.
Corrected October 31, 2023 · Resident Rights
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Potential for harm · D September 1, 2023
Assess the resident when there is a significant change in condition
Corrected October 31, 2023 · Resident Assessment and Care Planning
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Potential for harm · D September 1, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected October 31, 2023 · Resident Assessment and Care Planning
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Potential for harm · E September 1, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected October 31, 2023 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 18, 2025 | Fine | $9,110 |
| November 13, 2024 | Fine | $24,160 |
| November 13, 2024 | Payment Denial | 1 days |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 375173 · certified since May 1, 1994. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.