Fairview Fellowship Home For Senior Citizens, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairview, Oklahoma.
- Location
- 605 East State Road, Fairview, Oklahoma 73737
- CMS Provider Number
- 375427
- Inspections on file
- 16
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 4
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.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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