Fair Oaks Health & Rehabilitation

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to notify a physician of a resident's blood sugar level according to the physician's order for one of 11 residents in the survey sample, Resident #3.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement physicians' orders for three of 11 residents in the survey sample, Residents #6, #3, and #8.

Inspectors wroteBased on review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's right to a dignified existence and being respected for one of eleven residents in the survey sample, Resident #11 (R11).

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to place a call bell within a resident's reach for one of 11 residents in the survey sample, Resident #6.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain a clean, comfortable, home like environment in two of two facility elevators.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete an accurate MDS (minimum data set) for one of 11 residents in the survey sample, Resident #4.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store medications safely on one of three medication carts on the second floor, the cart serving room [ROOM NUMBER].

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow infection control procedures for one of 11 residents in the survey sample, Resident #7.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview and facility document review it was determined the facility staff failed to maintain a complete infection control program for one of one facility and for five of 48 residents in the survey sample, Residents #123, #65, #132, #90 and #104.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide dignity in caring for four of 48 residents in the survey sample, Residents #104, #112, #147, and #132.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review and facility document review, the facility staff failed to accommodate resident's needs for three of 48 residents in the survey sample, Residents #121, (R121), R144, R99 and R72. provide accommodations of resident needs by ensuring the call bell was within reach

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide required notification to the ombudsman following resident discharge for four of 48 residents in the survey sample, Residents #74, #104, #26, and #62.

Inspectors wroteBased on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the care plan for seven of 48 residents in the survey sample, R47, R46, R130, R23, R59, R62 and R76.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for five of 48 residents in the survey sample, Residents #147, #132, #62, #104, and #70.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to administer medications according to the physician's orders for one of 48 residents in the survey sample, Resident #76 (R76). For R76, the facility staff failed to administer Furosemide (for swelling), Gabapentin (for pain), Lorazepam (for anxiety), Losartan Potassium (for high blood pressure), Metoprolol (for high blood pressure), Mirtazapine (for depression), Oxycodone (for pain), Sertraline (for depression), Tamsulosin (for (BPH) benign prostatic hypertrophy (1)), Aspirin (for (CAD) coronary artery disease (2)), Lidocaine External Patch(for pain), Tylenol (for pain) according to the physician's order.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide care and services to prevent and treat a pressure injury (1) for two of 48 residents in the survey sample, Residents #74 and #98.

Inspectors wrote2. For R56, facility staff failed to place a C-PAP (continuous positive airway pressure) (1) mask is a plastic bag when not in use. R56 was admitted to the facility with diagnosis that included but not limited to sleep apnea (2). On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/23/2025, R56 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating R56 was cognitively intact for making daily decisions. On 02/03/25 at approximately 12:19 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/03/25 at approximately 2:49 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/03/25 at approximately 4:25 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. [...]

Inspectors wroteBased on resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 48 residents in the survey sample, R59.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of the frequency of physician visits at least every 60 days for two of 48 residents in the survey sample, R59 and R46.

Inspectors wroteBased on observations, resident/staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for one of 48 residents in the survey sample, R130.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one kitchen and in two of three nourishment rooms.

Inspectors wroteBased on clinical record review, staff interview and facility document review, the facility staff failed to provide rehabilitation services for one of 48 residents in the survey sample, Resident #76 (R76). For R76, speech therapist failed to follow the physician's order to evaluate and treat.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to notify the RP (responsible party) of a change in condition for one of 48 residents in the survey sample, R47.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide required Medicare discharge notice for three of three resident records reviewed, Residents #82, #104, and #26.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of required physician documentation after a resident is transferred to the hospital for one of 48 residents in the survey sample, R59.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement PASARR (preadmission screening and resident review) requirements for one of 48 residents in the survey sample, Resident #2.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 48 residents in the survey sample, Resident #10.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide toenail care for two of 48 residents in the survey sample, Residents #104 and #62.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a resident with limited range of motion for one of 48 residents in the survey sample, Resident #10.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide an environment to prevent avoidable accidents for one of 48 residents in the survey sample, Resident #90.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to administer tube feeding in a sanitary manner for one of 48 residents in the survey sample, Resident #131.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 48 residents in the sample R46. The facility failed to evidence provision of trauma informed care for R46. R46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post traumatic stress disorder), viral hepatitis and pulmonary fibrosis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/1/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence a physician writing a recommendation for a resident be admitted to the facility (admission note) for one of 48 residents in the survey sample, R59.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide medically related social services for one of 48 residents in the sample R46.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to provide pharmacy services for one of 48 residents in the survey sample, Resident #76 (R76). For R76, facility staff failed maintain the availability of Diltiazem (for high blood pressure), Ezetimibe (for cholesterol), and Methylcobalamin (for low iron) for administration.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure a medication error rate less than five percent for one of three residents observed during the medication administration observation, Resident #88 (R88). During the medication administration observation, two errors out of 38 used to treat glaucoma opportunities occurred, resulting in a six and twenty-five hundredths' percent (6.25%) percent medication error rate.

Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to implement a complete immunization program for two of five record reviews for immunizations, Resident #2 and Resident #97.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information that contained all required information.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to promote residents' rights for two of 12 residents in the survey sample, Residents #10 and #11.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain a physician ordered laboratory test for one of 12 residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for one of 12 residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review advance directives periodically with four of 42 residents in the survey sample, Residents #70, #71, #34 and #60.

Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens and in three of three nourishment rooms. 1. The facility staff failed to close a box containing a bag of diced carrots, exposing them to the environment, in one of one walk-in freezers. 2. The facility staff failed to label and date food available for use, found in the first floor, PARC unit and second floor nourishment room refrigerators in three of three nourishment room refrigerators.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to maintain a complete clinical record for five of 42 residents in the survey sample, Residents #47, #222, #121, #34 and #118.

Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to notify a resident's representative (RR) of a need to alter treatment for one of 42 residents in the survey sample, Resident #222.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to complete an accurate MDS (minimum data set) for three of 42 residents in the survey sample, Residents #120, #88, and #26.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to provide evidence of ADL (activities of daily living) care for one of 42 residents, Resident #424.

Inspectors wroteBased on staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed to follow the physician's order for medication administration one of 42 residents in the survey sample, Resident #372 (R372).

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to maintain a safe environment for one of 42 residents in the survey sample, Resident #42. The facility staff failed to ensure Resident #42 (R42) did not have access to [NAME]'s goo (1) a compound medicated cream containing medication that R42 was allergic to.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for one of 42 residents in the survey sample, Resident #30.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to coordinate hospice care services for one of 42 residents in the survey sample, Resident #121.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility staff failed to maintain the dumpster area in a sanitary manner to prevent pests. Approximately four clear gloves were noted on the ground around the dumpsters and bits of paper trash was observed on the ground throughout the area around the dumpsters

Inspectors wroteBased on observation, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to review and revise the comprehensive care plan for three of 33 current residents in the survey sample, (Resident #75, #51, and #94). The facility staff failed to review and revise the comprehensive care plans for Resident #75 to include the use of a physician ordered splint; for Resident #51 to include the use of bilateral lower extremity prostheses, and for Resident #94 to address the residents lower extremity edema and the use of physician ordered compression wraps to the residents bilateral feet and legs.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to store and serve food in a sanitary manner in the kitchen.

Inspectors wroteBased on observations, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for one of six residents in the medication administration observation, Resident #13; and for two other current residents in the survey sample, Residents #74 and #38. The MARs (medication administration record) for Resident #13, #74 and #38 inaccurately documented the wrong staff as administering medications to the residents on 4/7/21 at 9:00 a.m.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow infection control practices for two of 33 current residents in the survey sample, (Residents #336 and #38). A physical therapist failed to wear an isolation gown into Resident #336's room when he was providing treatment to the resident. The resident had a physician's order for droplet and airborne isolation precautions and the facility staff failed to sanitize an unclean blood pressure cuff before using it on Resident #38.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to serve lunch in a manner to promote resident dignity for one of 33 current residents in the survey sample, Resident # 101. CNA (certified nursing assistant) # 3 was observed standing next to Resident 101's bed, while feeding Resident # 101 their lunch meal.

Inspectors wroteBased on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide accommodations of resident needs for two of 33 current residents in the survey sample, Residents # 44 and # 49. The facility staff failed to ensure the call bells [a device with a button that can be pushed to alert staff when assistance is needed] for Resident #44 and Resident #49's were maintained within reach for use.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and implement the comprehensive care plan for three of 33 current residents in the survey sample, (Residents #336, #128, and #44). The facility staff failed to develop and implement a comprehensive care plan to include physician ordered transmission based precautions for Resident #336, failed to implement Resident #128's comprehensive care plan to administer oxygen as prescribed by the physician, and failed to develop a comprehensive care plan for Resident # 44's use of the physician ordered C-PAP [continuous positive airway pressure], with mask, and incentive spirometer.

Inspectors wroteBased on observations, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for nursing documentation for one of six residents in the medication administration observation, (Resident #13), and for two other current residents in the survey sample, (Residents #74 and #38). RN (registered nurse) #7 an agency nurse used a facility nurse's computer name and password to sign of medications that she administered to Residents #13, during the medication pass observation, and used a facility nurse's computer name and password to sign of medications that she administered to Resident #74 and #38.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure respiratory services were provided by qualified persons in accordance with the written plan of care for one of 33 current residents in the survey sample, Resident #128. Resident #128 was removed from her oxygen concentrator by CNA (certified nursing assistant) #10, who then switched and connected the resident to a new oxygen concentrator and turned on the machine, which had a flow rate of 3 LPM (liters per minute) and not the physician ordered 2 LPM. CNA #10 is not qualified to remove residents from or place residents on an oxygen concentrator.

Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide treatment and care in accordance with profession standards of practice and the comprehensive care plan for three of 33 current residents in the survey sample, (Resident #94, #120 and Resident #75). 1. Resident #94 was observed without compression wraps to both feet/legs (knee height) while awake for peripheral edema as ordered by the physician. 2. The facility nurse did not remain with Resident #120 for the duration of a nebulizer (1) treatment to ensure all of the nebulizer medication was administered as ordered by the physician. Resident #120 was observed unattended while receiving a nebulizer treatment and was observed pulling the nebulizer mask off his face multiple times during the treatment. 3. [...]

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care and services consistent with professional standards of practice, and the comprehensive person-centered care plan for three of 33 current residents in the survey sample, Residents #128, #44 and #73. 1. The facility staff failed to administer oxygen per the physician order and failed to follow professional standards of practice for the administration of oxygen for Resident #128. 2. The facility staff failed to store Resident #44's CPAP (continuous positive airway pressure) mask in a sanitary manner and failed to provide the resident with a incentive spirometer for use as ordered by the physician. 3. The facility staff failed to provide respiratory services in a sanitary manner for Resident #73. [...]

Inspectors wroteBased on observation, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to provide prosthesis (1) services for one of 33 current residents in the survey sample, Resident #51. Resident #51 was unable to wear their right prosthetic leg due to an improper fit which was known by facility staff and not addressed.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure residents' that require dialysis, receive services, consistent with professional standards of practice for one of thirty-three residents in the survey sample, Resident #436. The facility staff failed to evidence ongoing communication and collaboration with the dialysis facility for Resident #436, during her Monday/Wednesday/Friday dialysis treatments.