Sequoyah – Bartlesville

Non-compliance cited at a monitoring visit : 340:110-3-154(b)(2)(C)(v) names and dated signatures of review participants.

Initial service plan and 90 day review plan for one resident file does not contain all signatures of those participating.

Substantiated complaint : 340:110-3-154.3(e)(3) Prescription medications are administered, per container instructions, including only administering when the medication ...

Medication: Resident was given another resident's medication.

Found during a substantiated complaint investigation : 340:110-3-153.1(b) Personnel and responsibilities. The program recruits personnel with specialized skills, knowledge, and the cultural ...

Additional Non-Compliance Found During Investigation: Personnel and responsibilities: Personnel not demonstrating responsible behavior in reasonably ensuring residents' care and safety by reporting pertinent information to administration.

Substantiated complaint : 340:110-3-153.2(a) The program employs an adequate number of child care personnel meeting resident's needs, considering residents' ages ...

Supervision: Staff was passing medications and a resident walked up and took another resident's medications.

Non-compliance cited at a monitoring visit : 340:110-3-153.1(g)(1) References. The program obtains three references for personnel prior to employment. Copies are maintained in the ...

2 personnel files with only 2 references.

Non-compliance cited at a monitoring visit : 340:110-3-157(h)(1) At least one flush toilet, hand sink, and bathtub or shower in good working condition is available for every six ...

Rm 4: Toilet lid broken on toilet seat.

Found during a substantiated complaint investigation : 340:110-3-152(f)(1)(F) any time a resident receives emergency medical treatment by a licensed health care professional;

Additional Non-Compliance Found During Investigation: Notifications: It was found during the course of the investigation that the program did not notify Licensing within the next OKDHS business day of residents receiving emergency medical treatment by a licensed health care professional.

Non-compliance cited at a monitoring visit : 340:110-3-154(b)(1)(B)(vi) names and dated signatures of those participating in service plan development.

One resident file with initial service plan not signed by all participants.

Non-compliance cited at a monitoring visit : 340:110-3-154(b)(2)(A) The service plan is reviewed within 90-calendar days after development and at least every six months thereafter.

One resident file with no service plan completed within 90 calendar days after initial plan.

Non-compliance cited at a monitoring visit : 340:110-3-157(h) Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.

Room 7 - sink has soiled areas in the base of the sink and around the sink countertop.

Non-compliance cited at a monitoring visit : 340:110-3-157(h)(1) At least one flush toilet, hand sink, and bathtub or shower in good working condition is available for every six ...

Room 1 - Toilet has not lid for the back of the toilet. Room 8 - Toilet has no lid and is not in operable condition.

Non-compliance cited at a monitoring visit : 340:110-3-154(a)(6) Residents receive a medical examination by a licensed health care professional within 60-calendar days prior to ...

One resident file with medical exam not within 30 days of admission date.

Non-compliance cited at a monitoring visit : 340:110-3-154(b)(2)(A) The service plan is reviewed within 90-calendar days after development and at least every six months thereafter.

One resident file with no 90 day service plan.

Non-compliance cited at a monitoring visit : 340:110-3-157(n) Fire safety. The program complies with the state fire marshal's office regulations for construction and fire safety and ...

Fire inspection expired 04/05/2025.

Non-compliance cited at a monitoring visit : 340:110-3-165(5)(B)(i) All fire extinguishers are inspected, serviced, and tagged annually by a trained individual.

Fire extinguishers expired 01/31/2025.

Non-compliance, numerous, repeated or serious : 340:110-3-153.1(h)(1)(C) personnel applicants, prior to hire; however, the program may hire individuals, when:

One personnel with no completed background results prior to hire date.

Non-compliance cited at a monitoring visit : 340:110-3-153.1(m)(3)(E) When residents are in care on the facility premises or on a program-sponsored field trip, at least one personnel is ...

One personnel with expired CPR and First Aid.

Non-compliance cited at a monitoring visit : 340:110-3-153.1(o)(2)(A) an OKDHS-provided personnel information sheet, completed for each personnel upon employment and submitted to Licensing ...

One personnel information form not submitted to Licensing within 2 weeks of employment.

Non-compliance cited at a monitoring visit : 340:110-3-153.1(o)(2)(F) annual performance evaluation reports and notes relating to the individual's program employment;

One staff with no annual performance evaluation

Substantiated complaint : 340:110-3-154.3(e)(5) Medications are stored in a locked container and under the supervision of the designated personnel.

Medication: Medication was found on the counter in the medication room.

Substantiated complaint : 340:110-3-154.3(e)(1) On each shift, a personnel is designated ensuring compliance with the program's medication policy.

Medication : resident was in the medication room and took another resident's medication.

Non-compliance cited at a monitoring visit : 340:110-3-154(a)(1)(E) immunization record, medical and dental histories, including current medical problems;

One resident file with no immunization record available.

Substantiated complaint : 340:110-3-154.3(e)(3) Prescription medications are administered by the designated staff member only as part of a prescribed therapeutic ...

Health & Medical Services: Staff member gave a resident a peer's prescribed medications in addition to the resident's own medications.

Non-compliance cited at a monitoring visit : 340:110-3-153.1(o)(2)(A) an OKDHS-provided personnel information sheet, completed for each personnel and submitted to Licensing within two weeks ...

2 personnel information sheets not submitted to Licensing within 2 weeks of employment date.

Non-compliance cited at a monitoring visit : 340:110-3-163(1)(B) Windows and doors are in good repair, and free of broken glass or hazards.

Room 6- bathroom door has large hole where door has been busted in.

Non-compliance cited at a monitoring visit : 340:110-3-163(6) Lighting. Resident areas are well-lighted.

Room 1 - light in bathroom over the sink is not working.

Non-compliance cited at a monitoring visit : 340:110-3-154(b)(1) Comprehensive service plan. A written service plan is developed and documented for residents within 30-calendar days of ...

One resident file with no initial service plan available for Licensing to view.

Non-compliance cited at a monitoring visit : 340:110-3-154(b)(1) Comprehensive service plan. A written service plan is developed and documented for residents within 30-calendar days of ...

One resident file with initial service plan not within 30 days of admission date.

Non-compliance cited at a monitoring visit : 340:110-3-154(b)(2)(A) The service plan is reviewed within 90-calendar days after development and at least every six months thereafter.

One resident file with 6 month service plan review not timely.

Non-compliance cited at a monitoring visit : 340:110-3-154(e)(1)(I) signed documentation the resident and parents were provided copies of program policies.

One resident file with no signed documentation that resident and parents were provided program policies.

Non-compliance cited at a monitoring visit : 340:110-3-157(h)(1) At least one flush toilet, hand sink, and bathtub or shower in good working condition is available for every six ...

Bedroom #6, toilet seat broken with no lid attached. Bedroom #7, toilet tank has no lid cover.