Sayre Christian Village Nursing Home

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person centered care plan for each resident to meet a resident's nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (1) of forty-four (44) sampled residents (Resident #2). Resident #2's Comprehensive Care Plan (CCP), initiated 05/19/2021, revealed the facility failed to develop a CCP which specified how many staff members were required to safely assist the resident with a bath. Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 03/24/2023, revealed the facility assessed the resident as totally dependent for bathing requiring two (2) person physical assistance. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure residents were free of accident hazards as possible and failed to provide the necessary supervision and assistance to prevent accidents for one (1) of forty-four (44) sampled residents (Resident #2). Resident #2 was assessed to require the assistance of two (2) staff to assist with his/her baths and showers. However, the facility failed to ensure the resident's Comprehensive Care Plan (CCP) was reflective of the resident's assessed needs. On 03/30/2023, staff assisted the resident with a shower, without the assistance of staff, and the resident became combative causing the resident to sustain injuries which included a small laceration with some bruising and swelling; injuries to the eye; red markings on the left side of the neck; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.