Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Fairview Fellowship Home For Senior Citizens, Inc during CMS and state inspections, most recent first.
Staff failed to use required gowns during wound and catheter care for two residents needing enhanced barrier precautions. An LPN did not wear a gown and used soiled gloves to apply cream to open wounds after incontinent care, while two CNAs also omitted gowns during catheter care, despite stating they understood EBP protocols.
A resident with dementia and anxiety received unnecessary doses of hydroxyzine after an LPN changed a physician-ordered dose reduction from TID to BID back to TID without proper authorization, resulting in four extra doses being administered before the error was identified and corrected.
A resident with dementia and anxiety received four extra doses of hydroxyzine after an agency LPN entered an order for three times daily dosing, despite the physician's directive to reduce the dose to twice daily. The LPN made this change without proper verification, resulting in the resident receiving unnecessary medication until the error was identified by an RN.
A resident with severe cognitive impairment and anxiety received four extra doses of hydroxyzine after an agency LPN incorrectly entered a TID order, despite the physician's directive to reduce the dose to BID. The error was identified when another nurse reviewed the orders and confirmed the correct dosage with the physician.
Two residents with severe cognitive impairment and documented exit-seeking behaviors were not reassessed for wandering risk or provided with effective elopement prevention interventions. Despite repeated incidents of attempted elopement and ineffective redirection, only minimal interventions were used, and one resident was able to exit through an unsecured door, resulting in injury.
Two residents with cognitive impairment and a history of exit-seeking and wandering behaviors were not timely reassessed or had their care plans updated to include interventions for elopement prevention, despite multiple documented incidents and one resident sustaining an injury after elopement. Staff and leadership confirmed that interventions were not consistently implemented or documented in the care plans as required by facility policy.
The facility failed to maintain resident dignity during meal assistance, as staff were observed standing while assisting residents with eating, contrary to policy. Several residents with cognitive impairments and other conditions requiring meal assistance were affected. Staff admitted to leaving residents unattended and acknowledged the dignity issue of standing over residents during meals.
The facility failed to update care plans with fall interventions for two residents with dementia who experienced multiple falls. Despite implementing measures like increased supervision and fall mats, these interventions were not documented in the care plans. The facility's policy required new interventions to be added within 14 days, but this was not followed, leading to deficiencies in care planning.
A resident with dementia and a UTI was not consistently offered fluids, despite needing assistance with drinking. Observations showed staff frequently failed to offer drinks during care activities, and the resident's fluid intake was below the required amount. The MDS coordinator confirmed the expectation to offer fluids, but this was not consistently practiced.
The facility failed to assess risks and obtain informed consent before installing bed rails for two residents with severe cognitive impairment. The DON confirmed no entrapment assessments or consents were conducted for any residents using bed rails, affecting 23 residents.
The facility did not ensure RN coverage for eight consecutive hours a day, seven days a week, as required. The PBJ Staffing Data Report showed missing RN hours on specific dates, and HR confirmed the lack of RN coverage on one of those dates.
The facility failed to securely store controlled drugs, as a medication refrigerator at a nurse's station was not permanently affixed, and a lock box inside was unsecured. The refrigerator contained Lorazepam syringes and was located in an area with an open window to the hall. The nurse's station door was observed propped open, compromising the security of the controlled medications.
The facility's PBJ report failed to accurately reflect RN coverage for specific dates. The report for a period did not identify RN hours for certain days. Upon request, HR provided documentation confirming RN coverage for some of these dates, but the PBJ report still inaccurately reflected RN coverage on three of the four days in question.
The facility failed to maintain hand hygiene during meal assistance, implement enhanced barrier precautions for a resident with a catheter, and label oxygen equipment. Staff did not change gloves between assisting residents, a catheter bag was improperly handled, and oxygen tubing lacked required labeling. These actions were against the facility's policies, leading to deficiencies in infection control.
The facility failed to administer the pneumonia vaccine to two residents who had signed consents, despite the facility's policy requiring it. One resident had dementia, and the other had pneumonia and diabetes. The MDS Coordinator confirmed the absence of documentation for the vaccine administration in both the facility's records and the Oklahoma State Immunization Information System.
The facility failed to notify the OHCA after two residents experienced significant changes in their mental health diagnoses. One resident was diagnosed with unspecified psychosis and prescribed Seroquel, while another was diagnosed with delusional and anxiety disorders and prescribed Abilify and buspirone. The DON confirmed that no PASARR assessments were completed following these new diagnoses, and the facility lacked a PASARR policy.
A facility failed to document the use of bed rails in a resident's care plan, despite observations confirming their use for independence and repositioning. The facility's policy requires accurate care plans, but the Director of Nursing acknowledged the omission.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were properly implemented during wound and catheter care for two residents who required these precautions. Observations revealed that an LPN performed wound care on a resident's left lower leg and subsequent incontinent care without wearing a gown, as required by the facility's EBP policy. The LPN also used soiled gloves to apply cream to open wounds on the resident's buttocks after providing incontinent care, further deviating from proper infection control practices. The resident had chronic venous hypertension with ulcers on both lower legs and stage 2 pressure ulcers on the buttocks, with care plans and physician orders indicating the need for EBP. Additionally, two CNAs provided catheter care to another resident with an indwelling catheter for comfort measures, also without wearing gowns as mandated by the EBP policy. Both CNAs stated they understood and followed EBP protocols, despite not adhering to the required use of gowns during high-contact care activities. The ADON reported that staff had been educated on EBP practices, but the observed actions did not align with facility policy or training.
Incorrect Medication Order Leads to Unnecessary Psychotropic Drug Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of unspecified dementia and generalized anxiety disorder received unnecessary doses of a psychotropic medication due to incorrect medication orders. The resident's medication regimen was under review, and the consulting pharmacist recommended a gradual dose reduction (GDR) of hydroxyzine 25 mg, which was initially prescribed three times daily (TID) for anxiety. The physician agreed with the recommendation and ordered the dose to be reduced to twice daily (BID). The Director of Nursing (DON) entered the new BID order into the resident's chart as directed by the physician. However, an agency LPN subsequently changed the order back to TID without proper verification, despite the physician's confirmation of the BID order. The LPN stated that they believed the physician intended for the medication to remain at TID and entered the order accordingly, even though the DON and the physician had already confirmed the reduction to BID. This unauthorized change resulted in the resident receiving four additional doses of hydroxyzine between the dates the error occurred and when it was discovered. The error was identified when another nurse reviewed the resident's orders and noticed the discrepancy. The nurse confirmed with the physician that the correct order was for BID dosing, not TID. The facility's records and interviews confirmed that the LPN had altered the medication order without a physician's directive, leading to the administration of unnecessary medication doses to the resident.
Incorrect Medication Order Entry Led to Unnecessary Administration of Anti-Anxiety Medication
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and diagnoses of unspecified dementia and generalized anxiety disorder received an anti-anxiety medication, hydroxyzine, in a manner inconsistent with physician orders. The resident's medication regimen was reviewed by a consultant pharmacist, who recommended a gradual dose reduction (GDR) of hydroxyzine from three times daily (TID) to twice daily (BID). The primary care physician agreed and ordered the reduction, which was entered into the resident's chart by the Director of Nursing (DON). Despite the physician's order to reduce the hydroxyzine dose to BID, an agency LPN subsequently entered a new order for hydroxyzine 25 mg TID, contrary to the physician's instructions. This change was made after the LPN claimed to have clarified with the physician, but in reality, the physician had confirmed the BID order. The LPN admitted to changing the order to TID without proper verification, influenced by requests from medication aides, and not based on a new physician directive. As a result of the incorrect order entry, the resident received four additional doses of hydroxyzine 25 mg between the dates the error occurred and when it was identified. The error was discovered by an RN, who noticed the discrepancy and confirmed with the physician that the correct order was for BID dosing. The facility's records and interviews confirmed that the LPN's unauthorized change led to the administration of unnecessary medication doses.
Medication Order Error Leads to Unnecessary Doses Administered
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and diagnoses of unspecified dementia and generalized anxiety disorder received four additional doses of hydroxyzine 25 mg that were not ordered by the treating physician. The resident's medication regimen was reviewed by the consultant pharmacist, who recommended a gradual dose reduction (GDR) of hydroxyzine from three times daily (TID) to twice daily (BID). The primary care physician agreed and ordered the reduction, which was entered into the resident's chart by the Director of Nursing (DON). Despite the physician's order to reduce the hydroxyzine dose, an agency LPN entered a new order for hydroxyzine 25 mg TID, contrary to the physician's instructions. The LPN stated they believed the physician intended the resident to continue on the TID dose, despite confirmation from the physician for the BID order. This incorrect order resulted in the resident receiving four extra doses of hydroxyzine over several days. The error was discovered when another nurse reviewed the resident's orders and found the discrepancy. The nurse confirmed with the physician that the correct order was for hydroxyzine 25 mg BID, not TID. The DON and administrator confirmed that the LPN had changed the order without proper authorization, leading to the administration of unnecessary medication doses to the resident.
Failure to Prevent Elopement and Inadequate Supervision for Residents with Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for residents with known exit-seeking behaviors. One resident, admitted with dementia and a history of a femur fracture, was initially assessed as low risk for elopement. However, over several months, this resident exhibited repeated exit-seeking behaviors, including multiple documented attempts to leave the facility, both alone and with another resident. Despite these behaviors, the only intervention documented prior to the incident was redirection, which was repeatedly noted as ineffective. No additional interventions were added to the care plan, and the resident was not reassessed for wandering risk as required by facility policy. Another resident, also with severe cognitive impairment and a diagnosis of Alzheimer's disease, was assessed as a moderate risk for wandering upon admission. This resident also demonstrated exit-seeking and wandering behaviors on multiple occasions, but there was no documentation of reassessment for wandering risk or the addition of elopement prevention interventions to the care plan prior to the incident. Staff interviews confirmed that hourly location checks and redirection were the only interventions used, and these were discontinued after a short period without further action. Staff also reported a lack of knowledge regarding identification of residents at risk for elopement and appropriate interventions. The deficiency culminated in an incident where the first resident was able to exit the facility through a laundry room door that was supposed to be locked, resulting in a fall and injury outside the building. The facility's own policy required regular reassessment for wandering risk and the implementation of additional interventions for residents exhibiting exit-seeking behaviors, but these steps were not taken. The DON and administrator acknowledged that the residents were not reassessed or care planned appropriately, and that the door used for elopement was not secured as required.
Failure to Timely Review and Revise Care Plans for Residents with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for two of three sampled residents who exhibited exit-seeking and wandering behaviors. Both residents had cognitive impairments, including dementia and Alzheimer's disease, and were admitted with risk factors for wandering. Despite documented incidents of exit-seeking, attempts to leave, and actual elopement, the care plans for these residents were not updated in a timely manner to reflect necessary interventions for elopement prevention. For one resident, multiple nursing notes documented exit-seeking behaviors, including searching for keys, attempting to leave, and being found outside the facility after elopement, which resulted in a fall and injury. Although hourly location checks were initiated for a short period, these interventions were not documented in the care plan, and no interventions to prevent elopement were added until after the resident had already eloped and sustained an injury. The resident's care plan was not updated to include a wander guard or other preventive measures until after the incident occurred. The second resident, who also had severe cognitive impairment and a moderate risk for wandering, exhibited similar exit-seeking behaviors on multiple occasions. However, this resident was not reassessed for wandering or elopement risk after these incidents, and the care plan did not include a focus on elopement prevention until much later. Staff interviews confirmed that interventions such as redirection and hourly checks were used inconsistently and were not reflected in the care plans. The DON and administrator acknowledged that the residents were not reassessed or care planned for elopement risk in accordance with facility policy, and that interventions were not implemented or documented in a timely manner.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents who required assistance with meals were treated with dignity during meal times. Observations revealed that staff members, including CNAs, were standing while assisting residents with eating, which is against the facility's policy. This behavior was observed with several residents who had varying degrees of cognitive impairment and required different levels of assistance with eating. For instance, a CNA was seen standing over a resident with dementia while providing meal assistance, which was acknowledged as a dignity issue by the CNA. The report highlights specific instances where staff members did not adhere to the facility's policy of remaining seated while assisting residents with meals. In one case, a CNA was observed standing and moving between residents, providing assistance without sitting down, which could compromise the residents' dignity. Another CNA admitted to leaving a resident unattended with food in front of them to assist another resident, which resulted in the resident not receiving the necessary assistance for a period of time. The residents involved in these observations had various medical conditions, including dementia, Alzheimer's disease, Parkinson's disease, and stroke-related impairments, which affected their ability to eat independently. The care plans and assessments for these residents documented their need for assistance with meals, yet the staff's actions did not align with these documented needs, leading to a deficiency in maintaining the residents' dignity during meal times.
Failure to Update Care Plans with Fall Interventions
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated with fall interventions after multiple falls. Resident #32, who had dementia and severe cognitive impairment, experienced numerous falls from June 2023 to May 2024, some resulting in injuries such as skin tears and hematomas. Despite these incidents, the care plan for Resident #32 had not been updated with new interventions since December 2022. The MDS Coordinator acknowledged that while some interventions were implemented, such as increased supervision, they were not documented in the care plan. Resident #36, also diagnosed with dementia, experienced falls on several occasions between March and May 2024. Although interventions like a low bed and fall mat were used, these were not documented in the care plan. The comprehensive care plan for Resident #36 had not been updated with new interventions since November 2020. Staff members, including a CMA and LPN, confirmed that the interventions in place were not reflected in the care plan. The Director of Nursing (DON) confirmed that the facility's policy required new interventions to be added to the care plan after a fall, ideally within 14 days. However, this was not done for either resident, indicating a failure to adhere to the facility's policy and ensure accurate and up-to-date care plans for residents at risk of falls.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident diagnosed with dementia, urinary incontinence, and a UTI, who required assistance with eating and drinking. The resident's fluid intake was consistently below the estimated need of 1802 milliliters, with records showing significantly lower amounts consumed over several days. Despite a physician's note indicating the need to push fluids due to a UTI, the resident was not consistently offered drinks by the staff. Observations revealed that the resident's water was often placed out of reach, and staff did not offer fluids during routine care activities. On multiple occasions, staff members entered and exited the resident's room without offering a drink, even when providing personal care or transferring the resident. A family member reported not seeing staff offer drinks, and the resident was observed to have a significant decline, receiving hospice care. The MDS coordinator acknowledged the expectation for staff to offer fluids whenever in the resident's room, but this was not consistently practiced. The deficiency was highlighted by the lack of staff action to ensure the resident's hydration needs were met, despite clear indications and instructions to do so.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment and informed consent procedures were followed before the installation of bed rails for two residents. Resident #43, who had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs), was observed with a half bed rail in place. Despite the presence of the bed rail, there was no documented assessment for entrapment risks or informed consent in the resident's records. Similarly, Resident #168, who had severe cognitive impairment and required assistance with bed mobility and transfers, was also observed with bed rails in the upright position. The facility did not document the risks and benefits of the bed rails or obtain informed consent for their use. The Director of Nursing (DON) confirmed that no entrapment assessments or informed consents were conducted for any residents using bed rails, including Residents #43 and #168. The DON acknowledged that alternatives to bed rails were not considered prior to their installation. This oversight affected 23 residents identified as utilizing bed rails, indicating a systemic issue in the facility's approach to bed rail use and resident safety.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. The Payroll-Based Journal (PBJ) Staffing Data Report for the period from October 1, 2023, to December 31, 2023, indicated that the facility did not document RN hours for October 1, 2023, December 22, 2023, December 25, 2023, and December 30, 2023. On May 21, 2024, at 9:15 a.m., the facility's Human Resources (HR) department was asked to provide documentation proving that an RN had worked the required hours on the specified dates. Later that day, at 1:40 p.m., HR confirmed that there was no RN coverage in the building on October 1, 2023.
Improper Storage of Controlled Drugs
Penalty
Summary
The facility failed to provide a separately locked, permanently affixed compartment for the storage of controlled drugs in one of the two refrigerators used for drug storage. During an observation on May 21, 2024, a medication mini refrigerator was found at the nurse's station on hall five, sitting on the counter and not permanently affixed. Inside the refrigerator, a small metal lock box was also not affixed and contained controlled medications, specifically Lorazepam 0.5mg syringes. The nurse's station had an open window area to the hall, and on May 22, 2024, the door to the nurse's station was observed propped open, with the refrigerator still unsecured. An RN stated that the door was closed and locked most of the time. The Director of Nursing was informed of these observations on May 23, 2024.
Inaccurate RN Coverage in PBJ Report
Penalty
Summary
The facility failed to ensure that the Payroll Based Journal (PBJ) accurately reflected Registered Nurse (RN) coverage for specific dates. The PBJ Staffing Data Report for the period from October 1, 2023, to December 31, 2023, did not identify RN hours for October 1, December 22, December 25, and December 30, 2023. On May 21, 2024, at 9:15 a.m., the facility's Human Resources (HR) department was requested to provide documentation confirming RN coverage on these dates. Later that day, at 1:40 p.m., HR provided documentation showing RN coverage for December 22, December 25, and December 30, 2023. However, the PBJ report did not accurately reflect the RN coverage on three of the four days in question, indicating a discrepancy in the facility's staffing records.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper hand hygiene during meal assistance for several residents in the secure unit. Observations revealed that staff members, including CNAs and a CMA, did not change gloves or sanitize their hands when moving between residents, handling food, or after touching dirty dishes. This lack of hand hygiene was observed during the noon meal assistance, where staff used the same gloves to assist multiple residents, handle food items, and manage utensils without washing their hands or changing gloves. The facility also failed to implement enhanced barrier precautions for a resident with an indwelling catheter. During perineal care, the catheter bag was placed on the bed and subsequently fell to the floor, where it remained while care was provided. The catheter bag was then dragged across the floor before being hooked to the bed frame. The facility's policy stated that catheter bags should not touch the floor, and enhanced barrier precautions were not implemented for residents with indwelling catheters unless they were colonized with a multidrug-resistant organism. Additionally, the facility did not label or date oxygen tubing and humidification bottles for a resident using oxygen equipment. The resident had been hospitalized for pneumonia and a UTI and was on oxygen therapy. Observations showed that the oxygen concentrator in the resident's room had no labels on the tubing or humidification bottle, and the nasal cannula was not covered or protected. Staff acknowledged the lack of labeling, which was against the facility's policy requiring all oxygen equipment to be labeled and dated.
Failure to Administer Pneumonia Vaccination
Penalty
Summary
The facility failed to ensure that residents were administered the pneumonia vaccination as required. Specifically, two residents, one with dementia and another with pneumonia and diabetes, had signed consents for the pneumococcal vaccine, but there was no documentation in their records indicating that the vaccine had been administered. The facility's policy stated that pneumococcal vaccines should be offered between October and March each year and every five years unless specified otherwise by the primary physician. However, the MDS Coordinator confirmed that there was no record of the vaccines being administered, nor was there any record in the Oklahoma State Immunization Information System of the vaccine being previously administered.
Failure to Notify OHCA of Significant Mental Health Changes
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) after two residents experienced significant changes in their mental health diagnoses, which is a requirement for residents receiving mental health or intellectual disability services. Resident #12 was admitted with vascular dementia and anxiety, and later received a new diagnosis of unspecified psychosis, for which Seroquel was prescribed. Despite this significant change, the Director of Nursing (DON) confirmed that a PASARR II was not completed following the new diagnosis. Similarly, Resident #30 was admitted with type 2 diabetes and unspecified intellectual disabilities, and later diagnosed with depression and anxiety disorder. The resident was prescribed Abilify for delusional disorder and buspirone for anxiety disorder. However, the facility did not have a PASARR policy in place, and the DON acknowledged that no PASARR was completed after the new diagnoses of delusional and anxiety disorders. This oversight indicates a failure to comply with the necessary notification and assessment procedures for residents with significant mental health changes.
Failure to Document Bed Rail Use in Care Plan
Penalty
Summary
The facility failed to develop a care plan for the use of bed rails for a resident who had bed rails. The facility's policy on the MDS and Care Plan Process, revised in July 2023, emphasizes the importance of having an accurate care plan that identifies individualized approaches for each resident. However, upon review, it was found that the care plan for the resident did not document the use of bed rails. Observations on May 22, 2024, confirmed that the resident was using half bed rails in the upright position while in bed. The Director of Nursing (DON) acknowledged that the resident used bed rails for independence and repositioning but admitted that this was not documented in the care plan.
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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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Nursing homes near Fairview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summers Healthcare, Llc | 14.1 mi | ★★★★★ | 0 | 0 |
| Seiling Nursing Center | 26.2 mi | ★★★★★ | 4 | 0 |
| Garland Road Nursing & Rehab Center | 30.9 mi | ★★★★★ | 9 | 2 |
| The Commons | 31.6 mi | ★★★★★ | 0 | 0 |
| Baptist Village Of Enid | 32.8 mi | ★★★★★ | 2 | 0 |
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