Fairview Fellowship Home: Care Quality Failures - OK
The incident at Fairview Fellowship Home For Senior Citizens began September 24, when a physician agreed to reduce Resident #8's hydroxyzine prescription from 25 mg three times daily to twice daily following a pharmacist's gradual dose reduction request.
The Director of Nursing entered the new order for hydroxyzine 25 mg twice daily on September 25. But that same evening at 7:11 p.m., agency LPN #1 changed the order back to three times daily without physician verification.
"LPN #1 told them they knew the doctor meant TID and not BID so that was why LPN #1 entered the order as TID," RN #1 told inspectors on October 9. The nurse had discovered the unauthorized change on September 29 while checking Resident #8's orders.
The error wasn't caught for four days. Resident #8 received the higher dose from September 26 through September 29, until RN #1 spotted the discrepancy and had the medication aide hold the drug.
RN #1 then verified with the physician that the correct order was indeed twice daily, not three times as LPN #1 had entered.
The agency nurse later admitted the error to inspectors. "LPN #1 stated they changed the order for hydroxyzine 25 mg BID to TID without verifying the order was correct," according to the October 13 interview. "LPN #1 stated they put the order in as hydroxyzine 25 mg TID when it should have been BID."
But LPN #1 also told inspectors that medication aides had asked her to change the orders back to three times daily, suggesting confusion among staff about the correct dosage.
The timeline reveals multiple communication breakdowns. The pharmacist requested the dose reduction on September 23. The physician agreed on September 24. The Director of Nursing entered the correct order on September 25. Yet somehow, LPN #1 believed the medication aides' request to increase the dose back to the original level.
The administrator confirmed the sequence of events, stating that LPN #1 had initially called the physician and verified the twice-daily order but then entered it incorrectly as three times daily in the system.
"The administrator stated LPN #1 was an agency staff and was not allowed to return to the facility due to the error," inspectors documented.
The Director of Nursing provided additional context about the medication review process. The pharmacist had specifically requested a "gradual dose reduction" of the hydroxyzine on September 23, and the primary care physician agreed the next day.
Hydroxyzine is an antihistamine commonly used in nursing homes for anxiety and itching, but it can cause drowsiness and confusion in elderly patients. The medication carries particular risks for seniors, which likely prompted the pharmacist's reduction recommendation.
The incident highlights the complex chain of communication required for medication management in nursing homes. A pharmacist reviews medications, recommends changes, a physician approves modifications, nursing leadership enters new orders, and floor staff administer drugs according to those orders.
In this case, that chain broke when an agency nurse decided to second-guess a physician's explicit instructions.
The facility's response was swift once the error was discovered. The Director of Nursing stated that LPN #1 was "placed on a do not return from the agency as a result of the medication order error."
But the four extra doses had already been administered. The resident received medication at a higher level than the physician intended for nearly a week, despite the facility's systems designed to prevent exactly this type of error.
The violation occurred during a complaint investigation completed November 21, suggesting someone reported concerns about medication management at the facility.
Resident #8's experience illustrates how individual staff decisions can undermine physician orders and patient safety protocols, even when supervisors correctly implement medication changes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairview Fellowship Home For Senior Citizens, Inc from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Fairview Fellowship Home For Senior Citizens, Inc in Fairview, OK was cited for violations during a health inspection on November 21, 2025.
The Director of Nursing entered the new order for hydroxyzine 25 mg twice daily on September 25.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.