Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountain View Manor, Inc during CMS and state inspections, most recent first.
The facility did not complete criminal history background checks for two LPNs, even though its policy required screening employees for histories of abuse, neglect, or mistreatment through prior employer information and checks of licensing boards and registries. Employee file reviews showed no background check results for an LPN hired in late 2024 and another hired in mid-2025, while the administrator reported believing that nurses with valid licenses overseen by the state nursing board did not require separate background checks. At the time of the survey, 80 residents were identified as residing in the facility.
Staff failed to follow proper infection control practices during a noon meal service involving about 80 residents. A dietary aide placed a sanitizing bucket on a food prep table next to a food processor used for puréed items, wiped a prep table with a rag from the sanitizing bucket, and then handled food trays without handwashing. In a separate instance, a cook used a sanitizing rag as a potholder to remove a pan of burritos from the oven and then prepared meal trays without performing hand hygiene.
Surveyors identified that all occupied rooms on the memory care unit lacked operational call lights, despite facility policy requiring a calling system for each resident. During a unit tour, each of the 14 observed rooms was found without a call light, and staff interviews revealed that CNAs and the ADON reported call lights were not installed because they were considered a strangulation risk and safety hazard, leaving residents to holler out if they needed staff assistance.
Surveyors found that two residents were not provided documented opportunities to create advance directives. Review of their electronic health records showed no advance directive acknowledgment forms, despite their admissions having occurred earlier. A social services staff member confirmed the absence of these forms in the charts and explained that the forms were likely omitted from the admission packet when new copies were made.
A resident with dementia, depression, and moderately impaired cognition (BIMS score of 10) had an inaccurate quarterly assessment related to antipsychotic medication use. Although a physician order had discontinued the resident’s Olanzapine, the assessment documented that the resident received an antipsychotic daily during the seven-day look-back period. During interview, the DON acknowledged that the assessment information was inaccurate.
A resident dependent on supplemental O2 with a history of acute respiratory failure and other comorbidities was observed multiple times receiving humidified O2 via nasal cannula with undated tubing and a humidifier bottle and storage bag that had not been changed since late November, despite a physician order and facility policy requiring monthly replacement. The resident’s assessment did not reflect current O2 therapy, while the care plan documented continuous O2 use. An LPN acknowledged the lack of dating on the tubing and misinterpreted the frequency for changing equipment, and the DON confirmed that the equipment should have been dated and changed monthly but was not.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions policy requiring both gown and gloves for high-contact care activities, including wound care. An LPN performed wound care on two residents with documented open wounds using only gloves and no gown, despite physician orders for ongoing wound treatments. During interviews, the LPN and the DON stated that enhanced barrier precautions, including gowns, were used only when residents had active infections such as hepatitis C, which conflicted with the written policy specifying gown and glove use for any wound care requiring a dressing.
The facility failed to ensure that posted staffing information contained the required components and was accessible to all residents. On multiple occasions, the posted staffing information at the nursing station did not include the facility name and staffing hours. Additionally, there was no posted staffing information in the Alzheimer's unit. The DON confirmed the absence of posted staffing information in the Alzheimer's unit and admitted to being unaware of the requirements for posting staffing information.
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks for 9 out of 65 employees hired between 2016 and 2024. The HR manager could not provide the necessary clearance letters or explain the absence of these checks, and the employee roster did not list these employees as current eligible employees.
The facility failed to ensure accurate MDS coding for several residents, including errors in documenting diuretic use, falls, insulin use, and antipsychotic medication. These inaccuracies were confirmed by the MDS coordinator and the DON.
The facility failed to date multidose vials upon opening. During an observation, one vial of Tuberculin Purified Protein and two vials of Influenza vaccine were found opened and not dated. The ADON confirmed that the bottles should have been dated.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for two residents. One resident with chronic pain and morbid obesity and another with hemiplegia and vascular dementia were observed with bed rails in use, but there was no documentation of regular inspections. The DON and administrator confirmed the lack of documentation, indicating a gap in the facility's maintenance program.
The facility failed to ensure residents' personal privacy in the Alzheimer's unit. A resident with dementia complained about wandering residents entering their room. Observations confirmed unsupervised wandering, and staff admitted difficulty in redirecting residents. The administrator acknowledged the issue, stating that wandering is common and families are advised not to bring valuable items.
A resident with urinary incontinence and morbid obesity did not receive scheduled baths or showers as required. The electronic bathing records showed significant gaps, and the resident confirmed irregular bathing. Staff interviews revealed a lack of proper documentation, making it impossible to verify if the resident received the appropriate care.
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment before installing bed rails for two residents. Both residents were observed using bed rails without the required documentation and assessments, contrary to the facility's bedrail policy.
A resident with dementia, sleep disorder, and hypertension was inappropriately prescribed Olanzapine for dementia. The DON confirmed that dementia is not an appropriate diagnosis for this medication, indicating a failure to follow guidelines for psychotropic medication use.
Failure to Complete Criminal Background Checks for Nursing Staff
Penalty
Summary
The facility failed to complete required criminal history background checks for two sampled LPN employees, despite having a policy stating that employees would be screened for a history of abuse, neglect, or mistreatment by obtaining information from previous or current employers and checking appropriate licensing boards and registries. Record review showed that one LPN hired on 10/08/24 and another LPN hired on 06/25/25 had no criminal history or background check results in their employee files. During an interview, the administrator stated they believed background checks were not required for nurses because the Oklahoma nursing board managed nursing licenses and that a valid license was sufficient for nurses to work in Oklahoma. At the time of the survey, the administrator identified that 80 residents resided in the facility. This deficiency was identified through review of the facility’s undated abuse/neglect/exploitation policy, undated employee lists, and the personnel files of the two LPNs, as well as the administrator’s statements explaining the facility’s practice regarding background checks for licensed nursing staff.
Improper Hand Hygiene and Sanitizer Use During Meal Preparation
Penalty
Summary
The facility failed to prepare and handle food in a manner that minimized the risk of infection and cross-contamination during the noon meal service, which served approximately 80 residents. During a kitchen tour, dietary aide (DA) #1 was observed preparing puréed dessert while also carrying a bucket of sanitizing water to a sink located beside the prep table used for puréed food. After dumping the sanitizing water into the sink, DA #1 placed the bucket on the prep table next to the food processor used for food preparation. Later, DA #1 was observed wiping down a prep table with a rag from the sanitizing bucket and then handling food trays without performing hand hygiene. In a separate observation, cook #1 removed a large sheet pan of burritos from the oven using a sanitizing rag as a potholder and then proceeded to prepare meal trays without washing their hands. The dietary manager (DM) later stated that staff should have washed their hands and should not have had the sanitizing bucket or rag in the area where food was being prepared.
Failure to Provide Call Lights in Memory Care Unit
Penalty
Summary
Surveyors found that the facility failed to ensure operational and available call lights for all 14 occupied rooms on the memory care unit, where 22 residents resided. During a tour of the unit on 01/13/26 between 9:01 a.m. and 9:14 a.m., each of the 14 observed rooms was noted to have no call light. An undated Call Light Policy stated that a calling system must be available for each resident in the nursing home, but this was not in place on the memory care unit. In interviews, a CNA reported being told that the rooms did not have call lights because they were considered a strangulation risk, and stated that if a resident needed staff assistance they would have to holler out. The ADON similarly stated that the memory care unit did not have call lights because they were viewed as a safety hazard. These observations and statements show that the facility had intentionally not provided call lights in the memory care unit bathrooms and bathing areas despite its own policy requirement that a calling system be available for each resident.
Failure to Offer and Document Opportunity for Advance Directives
Penalty
Summary
The facility failed to honor residents' rights to be offered the opportunity to formulate an advance directive by not ensuring that required advance directive acknowledgment forms were present in the records of two sampled residents. Record review showed that one resident, admitted on an unspecified date, had no advance directive acknowledgment form in the electronic health record. A second resident, also admitted on an unspecified date, likewise had no advance directive acknowledgment form documented in the electronic health record. During an interview on 01/14/26 at 11:33 a.m., a social services staff member confirmed that there were no advance directive acknowledgment forms in these residents' charts and stated that the form must have been left out of the admission packet when additional copies were made. These findings occurred in the context of a census of 80 residents, with 18 residents sampled for review of advance directives, and demonstrated that at least two residents and/or their representatives were not provided the documented opportunity to create an advance directive as required.
Inaccurate Assessment of Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident receiving antipsychotic medications. Record review showed a physician order dated 11/12/25 discontinuing the resident’s Olanzapine, an antipsychotic medication. However, the quarterly assessment dated 11/25/25 documented that the resident had received an antipsychotic medication daily during the seven-day look-back period. The same assessment showed the resident had a BIMS score of 10, indicating moderately impaired cognition for daily decision making, and listed diagnoses including dementia and depression. During an interview on 01/20/26 at 10:39 a.m., the DON stated that this assessment was inaccurate, confirming the discrepancy between the medical record and the assessment documentation. This deficiency involved 1 of 18 sampled residents reviewed for assessments, with the DON identifying that 80 residents resided in the facility at the time of the survey.
Failure to Change and Date Oxygen Equipment per Physician Order and Policy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not dating and changing oxygen equipment as ordered for one resident using humidified oxygen. On multiple observations over several days, the resident was seen in bed with humidified oxygen delivered via nasal cannula, with the nasal cannula and oxygen tubing not dated. The humidifier bottle and a storage bag taped or hanging from the oxygen machine were consistently dated 11/26/25, indicating they had not been changed since that date. The facility’s undated oxygen policy stated that oxygen tubing was to be changed at least monthly for infection control, and a physician’s order dated 10/16/23 directed that the resident’s oxygen tubing and humidifier be replaced monthly related to a diagnosis of acute respiratory failure. The resident’s annual assessment dated 10/15/25 documented a BIMS score of 9, indicating moderate impairment in daily decision-making, and listed diagnoses including dependence on supplemental oxygen, acute upper respiratory infection, major depressive disorder, anxiety disorder, and need for assistance with personal care. The assessment did not show that the resident was receiving oxygen therapy, while a care plan dated 01/13/26 documented continuous oxygen administration at 2–3 L/min by nasal cannula and concentrator. During interviews, an LPN confirmed the resident was receiving 4 L of oxygen via nasal cannula, acknowledged the tubing was not dated, and believed the order was to change all equipment weekly, while stating the MAR/TAR would indicate when changes were due. The DON later stated the oxygen tubing should have been dated and that the humidifier bottle and storage bag should have been changed monthly per physician orders but were not.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not using enhanced barrier precautions during wound care for two residents. On 01/14/26 at 9:05 a.m., LPN #3 provided wound care to Resident #49 after gathering supplies and entering the resident’s room. LPN #3 donned gloves but did not don a gown, despite the facility’s undated Enhanced Barrier Precautions policy stating that providers and staff must wear gloves and a gown for high-contact resident care activities, including wound care for any skin opening requiring a dressing. Resident #49’s annual assessment dated 12/17/25 showed severe impairment in daily decision making, memory problems, and diagnoses including dementia, depressive disorder, anxiety disorder, chronic pain, and a disorder of the skin and subcutaneous tissue. A physician order dated 01/02/26 directed Betadine application to both heels and specific wound care to the right buttock involving cleansing, application of Santyl or Anasept, calcium alginate, and bordered gauze until resolved. On 01/14/26 at 9:30 a.m., LPN #3 was again observed providing wound care, this time to Resident #75, and similarly donned only gloves without a gown. Resident #75’s annual assessment dated 11/22/25 showed no cognitive impairment with a BIMS score of 14 and diagnoses including congestive heart failure, anxiety disorder, pain, and an open wound of the left buttock, with no pressure ulcers noted. A physician order dated 01/12/26 directed cleansing of the left buttock wound, patting dry, and applying Medihoney and calcium alginate, then covering with bordered gauze once daily and as needed. During an interview at 9:37 a.m., LPN #3 stated that PPE such as gowns and face shields were needed only if a resident had hepatitis C or an active infection and that only gloves were needed for wound care. At 9:40 a.m., the DON stated that enhanced barrier precautions were used when a resident had an active infection, indicating facility practice inconsistent with the written Enhanced Barrier Precautions policy requiring gown and gloves for wound care as a high-contact activity.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to ensure that posted staffing information contained the required components and was accessible to all residents. On multiple occasions, the posted staffing information at the nursing station did not include the facility name and staffing hours. Additionally, there was no posted staffing information in the Alzheimer's unit. The Director of Nursing (DON) confirmed the absence of posted staffing information in the Alzheimer's unit and admitted to being unaware of the requirements for posting staffing information. This deficiency had the potential to affect all 73 residents residing in the facility.
Failure to Obtain Criminal Background Checks for Employees
Penalty
Summary
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 9 out of 65 employees hired between 2016 and 2024. The employees without background checks included CNAs, dietary aides, a social services assistant, activity assistants, and a housekeeper. The facility's policy required criminal background checks for all prospective employees, but these checks were not documented for the specified employees. The employee roster provided by OK Screen did not list these employees as current eligible employees, and the HR manager could not provide the necessary clearance letters or explain the absence of these checks. On April 24, 2024, the facility provided a clearance letter for one activity assistant, but OK Screen employees reported that the letter was not sent by their agency and that the assistant had not been fingerprinted. The HR manager, who was home sick, reported via phone that they could not provide the email from OK Screen with the clearance letter and that they delete these emails after printing the letters. The HR manager also reported that the employees were in the OK Screen system at one time but did not know why they were not on the current roster. The administrator confirmed that the employees should have had criminal background checks and clearance letters in their files.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for several residents. Resident #23 was documented as receiving a diuretic and having two falls with no injury, but the medical record showed no order for a diuretic and only one fall without injury. MDS coordinator #1 confirmed these errors. Resident #10 was documented as having a fall with major injury in both an annual and a quarterly assessment, but the medical record did not support this. MDS coordinator #1 confirmed the coding errors for Resident #10 as well. Resident #9 was documented as receiving insulin injections 7 of 7 days during the look-back period, but the medication list showed no insulin injections. The DON confirmed this was a coding error. Resident #17 was documented as taking an antipsychotic 7 of 7 days during the look-back period, but the current medication list showed no antipsychotic medication. The DON confirmed this was also a coding error. These inaccuracies in MDS assessments indicate a failure to ensure accurate resident assessments.
Failure to Date Multidose Vials Upon Opening
Penalty
Summary
The facility failed to ensure multidose vials were dated upon opening. During an observation of the north hall medication refrigerator, it was found that one vial of house stock Tuberculin Purified Protein and two vials of multi-use Influenza vaccine were opened and not dated. The Assistant Director of Nursing (ADON) confirmed that the bottles should have been dated when opened. This deficiency was identified in a facility housing 73 residents.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for two residents. Resident #51, who had diagnoses including urinary incontinence, chronic pain, and morbid obesity, was observed with a half bed rail in the up position to assist with turning. The resident's care plan documented the use of the bed rail, but there was no evidence of regular inspections. Similarly, Resident #57, who had diagnoses including hemiplegia and vascular dementia, was observed with a half bed rail in the up position. The care plan for this resident did not document the use of a bed rail, and there was no evidence of regular inspections for this resident either. The Director of Nursing (DON) identified four residents with bed rails and confirmed the lack of documentation for regular inspections. The maintenance staff reportedly checked the bed rails routinely, but no records were kept. The administrator and DON both acknowledged the absence of documentation for the regular inspections of bed rails for Residents #51 and #57, highlighting a gap in the facility's maintenance program to ensure the safety of bed equipment.
Failure to Ensure Residents' Personal Privacy
Penalty
Summary
The facility failed to ensure residents' right to personal privacy for one resident sampled for personal privacy. Resident #40, who was admitted with diagnoses of hypertension, dementia, and thyroid disorder, complained about wandering residents entering their room. During an observation of the Alzheimer's unit, residents were seen going in and out of several rooms without supervision. An unknown resident was found sleeping in an unoccupied room. CNA #4 confirmed that only two staff members were assigned to the unit and admitted that they try to redirect wandering residents but are not always successful. Resident #40's roommate also complained about wandering residents trying to take their belongings. The administrator acknowledged the issue, stating that wandering is common in the Alzheimer's unit and that families are informed not to bring valuable personal items upon admission.
Failure to Ensure Scheduled Bathing for Resident
Penalty
Summary
The facility failed to ensure that a resident with urinary incontinence and morbid obesity was bathed as scheduled. The resident, who was moderately cognitively impaired and required substantial assistance with bathing, was supposed to receive a bath or shower three times a week according to the facility's shower schedule. However, the electronic bathing records for February, March, and April 2024 showed significant gaps in documentation, with the resident being bathed only a fraction of the scheduled times and no consistent documentation of refusals. The resident confirmed that they had not received showers regularly and often had to demand assistance from the staff. Interviews with staff, including a CNA and a corporate nurse consultant, revealed that showers should have been documented as either completed or refused in the electronic bathing record. The lack of documentation made it impossible to verify if the resident received the appropriate number of baths or showers. The Director of Nursing (DON) also confirmed that all baths should have been documented, whether completed or refused.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side rails for two residents. Resident #51, who had diagnoses including urinary incontinence, chronic pain, and morbid obesity, was documented to use a left half rail to assist with turning. However, there was no documentation of alternatives prior to the use of side rails or an entrapment risk assessment in the clinical record. The resident was observed with the bed rail in the up position and stated it was used to assist with turning. The facility's bedrail policy required attempts to use alternatives and an entrapment risk assessment before installing bed rails, which was not followed in this case. Resident #57, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction and vascular dementia, was documented to be severely cognitively impaired and dependent on most ADLs. The care plan did not document the use of bed rails, and there was no documentation of alternatives or an entrapment risk assessment in the clinical record. The resident was observed with a half bed rail in the up position and stated it was used to assist with turning. The administrator and DON confirmed that the required documentation and assessments were not completed, as they believed the rails were not used as restraints and thus did not require full compliance with the bed rail policy.
Inappropriate Psychotropic Medication Prescription
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medication without a specific diagnosis condition. A resident admitted with diagnoses of dementia, sleep disorder, and hypertension was prescribed Olanzapine 5mg every evening for dementia. The Director of Nursing (DON) later reported that dementia is not an appropriate diagnosis for Olanzapine and that the diagnosis should be changed. This deficiency was identified during a record review and interview, highlighting the facility's failure to adhere to guidelines for psychotropic medication use.
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Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Henryetta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Henryetta Community Skilled Healthcare & Rehab | 1.8 mi | ★★★★★ | 0 | 0 |
| Rainbow Terrace Care Center | 10.8 mi | ★★★★★ | 0 | 0 |
| Highland Park Health Care | 12.7 mi | ★★★★★ | 0 | 0 |
| Woodlands Skilled Nursing And Therapy | 13.5 mi | ★★★★★ | 0 | 0 |
| Okemah Care Center | 17.9 mi | ★★★★★ | 7 | 0 |
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