Sayre Christian Village Nursing Home

Based on observation, interview, and review of the facility's policies, the facility failed to prepare, store, and serve food under sanitary conditions. Observation of the Dietary Manager on 05/11/2026 at 2:00 PM, 2:20 PM, and 4:47 PM, revealed he performed hand hygiene at the hand sink and turned off the faucet with his bare hands.Observation of the resident nourishment refrigerator on Unit 2 on 05/11/2026 at 4:40 PM, revealed three clear plastic pitchers filled three-quarters full of a brown liquid substance. Further observation revealed one clear pitcher dated 05/04/2026 not labeled, and the other two pitchers with no date or label.The findings include: Review of the facility's policy titled, Hand Hygiene, dated 2024, revealed the process for hand hygiene technique when using soap and water included to rinse hands with water, dry thoroughly with a single-use towel, and use a clean towel to turn off the faucet. Further review revealed all staff would perform proper hand hygiene procedures in all locations within the facility. Review of the facility's policy titled, Food Safety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the residents' appeal rights and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 3 of 7 residents sampled for transfer and/or discharge, Resident (R) 1, R7, and R11. The findings include:Review of the facility's policy titled, Bed Hold Notice, reviewed/revised 03/05/2025, revealed it was the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. 1. Review of R1's Face Sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's policy, the facility failed to maintain an effective cleaning and disinfection program for shared resident-care equipment. This affected 2 out of the 3 facility's Hoyer sit-to-stand lifts, one on the 300 Unit and one on the 200 Unit.The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 01/01/2025, revealed cleaning was the removal of visible soil from objects and surfaces and normally was accomplished manually or mechanically using water with detergents or enzymatic products. Additionally, the policy stated each user was responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. Per the policy, multiple-resident use equipment shall be cleaned and disinfected after each use. Observation on 05/14/2026 at 8:37 AM of the 300 Unit and observation on 05/14/2026 at 10:36 AM in the equipment storage area on the 200 Unit revealed the Hoyer sit-to-stand lifts located in a side area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the facility's policy, the facility failed to provide completed pre- and post-dialysis communication documentation for 1 of 1 dialysis residents, Resident (R) 5. Review of documentation for 12 dialysis visits for R5, from 04/17/2026 through 05/13/2026, revealed communication forms were either unavailable or incomplete.The findings include: Review of the facility's policy titled, Hemodialysis, revision date 08/23/2024, revealed the facility would provide the necessary care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences to meet the special medical, nursing, mental, and psychosocial needs of the resident receiving hemodialysis. Further review revealed the facility would assure each resident received care and services consistent with professional standards of practice which included ongoing assessments before and after dialysis treatments and ongoing communication with the dialysis facility. Additional review revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's policy, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 sampled residents, Resident (R) 12 and R99.The findings include: Review of the facility's policy titled, Medication Storage, implemented date 01/2025, revealed medications would be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and be sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Additional review revealed the policy did not address labeling medications. Further review revealed external products, such as disinfectants and drugs for external use, were stored separately from internal and injectable medications. Observation on 05/13/2026 at 4:08 PM of the 200 Hall medication refrigerator revealed one canister labeled F-Magic Butt/Lidocaine Cream to apply topically to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the facility's documents, the facility failed to ensure residents and resident representatives were informed, using appropriate language, that binding arbitration agreements explicitly were not required as a condition of admission explicitly provided the residents or resident representatives the right to rescind the agreement within 30 days of signing it for 5 of 5 residents reviewed for arbitration agreements, Resident (R) 32, R58, R117, R127, and R131. Additionally, interview with three residents (R58, R127, R131) that signed agreements, including one as recently as 04/01/2025 (R131), did not recall the discussion of arbitration or signing of arbitration agreements. The findings include: Review of the facility's document Arbitration and Mediation agreement, not dated, revealed appropriate verbiage was not included on the form. The form did not indicate it was an optional form for the resident to complete; did not indicate it was not a requirement for the resident's admission; and did not indicate residents or representatives had 30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility document review, Centers for Disease Control and Prevention guidelines, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 34 sampled residents, Resident (R) 11, R34, R36, R119, R125, and R150. Observations revealed R11 and R34 had indwelling urinary catheter drainage bags resting on the floor; a gait belt was used on R36 without its prior disinfection; a blood pressure cuff was used on R125 and not disinfected after its use; R150's medications were placed on an unclean surface without using a barrier; R119's food was handled by a staff member with ungloved hands; and a dietary staff member's badge was resting in a resident's food. The findings include: Review of the facility's policy titled, Infection Surveillance, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 4 sampled residents, Resident (R) 34 and R120. The findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, revised 01/30/2025, revealed staff would ensure the call light was within reach of the resident and secured as needed. Further review revealed the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of the facility's policy titled, Resident Rights, undated, revealed the resident had the right to a dignified existence and self-determination. Review of the facility's policy titled, Safe and Homelike Environment, undated, revealed the facility would provide a safe, clean, comfortable, and homelike environment. 1. Review of R34's admission Record revealed the facility admitted the resident on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's abuse and Resident's Rights policies, it was determined the facility failed to protect residents from abuse for one (1) of forty-four (44) sampled residents (Resident #20). Resident #21 alerted State Registered Nursing Assistant (SRNA) #20 on the morning of 10/13/2023 that during the night when he/she had been sleeping, Resident #20, his/her roommate, struck him/her on the head with his/her iPad waking him/her up. The findings include: Review of the facility's Abuse Policy, dated 08/27/2019, revealed residents had the right to be free from abuse. Continued review revealed abuse was defined to include the willful infliction of injury with resulting physical harm, pain, or mental anguish. Review of the facility's Resident Rights policy revised 12/2016, revealed residents had the right to be treated with respect, kindness, and dignity, as well as the right to be free from abuse. 1. Review of Resident #21's Face Sheet revealed the facility admitted the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the facility's policy, and the Police Report Number: 2023-00059001 it was determined the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience and were not required to treat the resident's medical symptoms for one (1) of forty-four (44) sampled residents (Resident #2). On 03/30/2023, State Registered Nursing Assistant (SRNA) #3 (Agency Aide) provided Resident #2 a bath without assistance from other staff. Interview with SRNA #3, on 10/31/2023, revealed she was not briefed on how to provide care for Resident #2 when the resident became combative during the bed bath and tried to hit and scratch her. SRNA #3 stated she held the resident's hands to prevent the resident from hitting her. Resident #2 pulled back, and his/her hands slipped. The resident smacked himself/herself in the face which resulted in injuries that included a laceration to the resident's right eye. Refer to F656 The findings include:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of facility's policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations on 02/05/2020 of the nourishment rooms on the 100 and 200 unit revealed numerous snacks undated in the nourishment drawers. The findings include: Review of the facility's policy, titled Dry storage dated 2013, revealed to store, prepare and serve food in accordance with Federal, state and local sanitary codes. Continued review revealed foods would be labeled as to content and dated. Further review revealed stock will be rotated on a first in first out (FIFO) basis. Observations of the 200 unit resident nourishment room, on 02/05/2020 at 9:00 am revealed snacks not dated for four (4) ginger bread cookies, eight (8) strawberry delight cookies, one (1) oatmeal creme cookie and two (2) peanut butter crackles. Observation of the 100 unit resident nourishment room, on 02/05/2020 at 9:10 AM, revealed snacks not dated for five (5) marshmallow pies, one (1) ginger…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain clinical records that are accurately documented for one (1) of twenty-four (24) sampled residents (Resident #8). Review of Resident #8's Physician Orders revealed an order to Cleanse Stage 4 pressure wounds to right ischium and sacrum with normal saline, pat dry, apply alginate calcium with silver, cover with an abdominal (ABD) pad (wound dressing) and secure with pinc (zinc oxide-based adhesive tape) tape two (2) times daily, with a start date of 01/22/2020. However, review of the Treatment Administration Record revealed no documented evidence of treatment being signed out as administered from 01/22/2020 until 02/06/2020. The findings include: Interview with the facility's Director of Nursing, on 02/06/2020 at 4:32 PM, revealed maintaining accurate resident records is a standard of practice and there is no policy related to the accuracy of resident records. Review of Resident #8's clinical record revealed the facility admitted the resident on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.