Fair Oaks Health Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was transferred with a mechanical lift in a safe manner which applies to 1 of 5 residents (R1) reviewed for safe transfers in a sample of 5. This failure resulted in R1 falling from a mechanical lift sling sustaining a subdural hematoma. This past compliance occurred from 1/23/26 to 1/29/25.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform a safe wheelchair transport for a high fall risk resident for 1 of 3 residents (R1) reviewed for safety in the sample of 4. This failure resulted in R1 falling forward from the wheelchair and sustaining a broken nose and a laceration to his forehead that required sutures. Findings Include:On 10/9/25 at 10:10 AM, V9 (Certified Nursing Assistant -CNA/Restorative Aide) pushed R1 in his wheelchair from the dining room to a seating room without footrests in place. R1's shoes came in contact with the floor four times during the transport of approximately 25 feet. R1 was well groomed with a bandage on the middle of his forehead. R1 had a privacy bag for his indwelling catheter directly under the seat of his chair. The surveyor asked R1 how he hurt his head. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the physician of resident's rash on the day it was identified. This applies to 1 of 4 (R1) in the sample of 4 reviewed for notification.

Inspectors wroteBased on interview and record review the facility failed to assess a resident after a rash was observed by staff. This applies to 1 of 4 (R1) in the sample of 4 reviewed for assessments.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the correct portion of vegetables. This applies to 5 of 5 residents (R17, R21, R4, R6, & R11) reviewed for menus in the sample of 12 and 3 residents (R16, R1, & R80) outside the sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to measure food temperature on the steam table in a manner to prevent cross-contamination. This applies to 5 of 5 residents (R17, R21, R4, R6, & R11) reviewed for menus in the sample of 12 and 3 residents (R16, R1, & R80) outside the sample.

Inspectors wroteBased on interview and record review the facility failed to immediately initiate potential lifesaving interventions for 1 of 1 resident (R27) reviewed for quality of care in the sample 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with pressure ulcers for 1 of 4 residents (R18) reviewed for pressure in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were put in place for a resident with a history of falls, failed to ensure the resident's fall risk assessment was reassessed after a fall with injuries, and failed to develop a care plan showing he was a fall risk and identify interventions to prevent further falls for 1 of 1 resident (R11) reviewed for falls in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with an indwelling urinary catheter had physician care orders in place for 1 of 5 residents (R25) reviewed for catheters in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate reconciliation of controlled substances. This applies to 1 of 1 resident (R18) reviewed for controlled substances in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross-contamination when assisting a resident with their toileting needs, and failed to ensure staff wore the proper PPE (personal protective equipment) while providing direct care to a resident on enhanced-barrier precautions for 1 of 2 residents (R18) reviewed for infection control in the sample of 12, and 1 resident (R83) outside the sample.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a high fall risk resident was transferred with a gait belt for 1 of 5 residents (R1) in the sample of 5 reviewed for safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was within the reach of a resident to call staff for assistance for 1 of 1 resident (R5) reviewed for call light accessibility in a sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents requiring assistance with incontinence care for 2 of 12 residents (R21, R281) reviewed for activities of daily living in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure injury treatments were in place for 2 of 4 residents (R281, R21) reviewed for pressure injuries in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall prevention measures were in place for 1 of 1 resident (R15) reviewed for safety and supervision in a sample 12.

Inspectors wroteBased on interview and record review the facility failed to monitor and record weights for residents who had sustained weight loss and/or were at risk for weight loss for 3 of 6 residents (R6, R281, R21) reviewed for weight loss in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident on psychotropic medications was assessed for a gradual dose reduction (GDR) for 1 of 5 residents (R15) reviewed for unnecessary medications in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menus were followed for a resident on a pureed diet. This applies to 1 of 1 residents (R279) reviewed for dietary services in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents on a puree diet with the correct consistency. This applies to 1 of 1 residents (R279) reviewed for puree diets in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medical equipment was disinfected between residents to prevent cross contamination for 3 of 12 residents (R9, R22 and R23) reviewed for infection control in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dishwasher was sanitizing dishes, failed to label and date food in the freezer, and failed to ensure staff was wearing hair nets, for all 37 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were implemented for a resident at high risk for pressure ulcers for 1 of 3 residents (R8) reviewed for pressure ulcers in the sample of 12.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise a resident with dysphagia while eating for 1 of 12 residents (R219) reviewed for supervision in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to ensure a psychotropic medication had a stop date for 1 of 6 residents (R3) reviewed for psychotropic medications in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff waited 3-5 minutes in between the administration of two different eye drop medications (antibiotic eye drops and lubricating eye drops) for 1 of 4 residents (R119) reviewed for medication administration in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore an N95 mask while in the room of a resident on contact droplet isolation, for 1 of 12 residents (R3) reviewed for infection control in the sample of 12.