Fair Oaks Lodge

Inspectors wroteBased on observation and interview, the facility failed to ensure the medications were secured for 2 of 3 medication storage rooms. In addition, the facility failed to secure a medication cart in public space for 17 residents. (R15, R62, R52, R57, R65, R64, R63, R53, R54, R55, R13, R56, R58, R59, R61, R60, R33)

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure that the residents' ability to self-administer medications (SAM) was assessed prior to leaving medications with the resident for 2 of 2 residents (R11, R34), reviewed for medications left at the bedside.

Inspectors wroteBased on observation, interview and document review the facility failed to assess for restraints for 2 of 2 residents (R29 and R47) reviewed for use of a seatbelt. R29's quarterly minimum data set (MDS) dated [DATE], indicated R29 was cognitively intact, R29 was dependent on staff for activities of daily living. MDS section P indicated R29 had no wheelchair restraint in use. R29 had diagnoses that included diabetes, hypertension, history of transient ischemic attack (TIA- mini stroke), and hemiplegia (loss of voluntary movement) and hemiparesis (weakness) following cerebral infarct (stoke). R29's care plan dated 2/21/26, indicated R29 was able to safely use power wheelchair with interventions that included provide verbal cues and reminders when approaching elevator and use seat belt. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the required nurse staffing information was posted daily. This deficient practice had the potential to affect all residents who resided in the facility and/or any visitors who may have wished to view the information.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure safe transport with a facility van for 1 of 3 residents (R1). This resulted in an immediate jeopardy (IJ) for R1 when she slid out of wheelchair during transport, resulting in fractures. The immediate jeopardy (IJ) began on 6/11/25, at approximately 10:00 a.m., when the transport driver (TD) transported R1 in the facility van without the use of a seatbelt. R1 slid out of her wheelchair during transport resulting in closed fractures to the right and left tibias (the larger bone of the lower leg) and closed fracture of left femur (the main bone in your thigh that connects your hip to your knee and is your body's largest and strongest bone). The IJ was identified on 6/18/25, the administrator was notified of the IJ on 6/18/25, at 1:32 p.m. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to implement interventions to provide adequate monitoring and supervision for 2 of 3 residents (R1, R2) who reside on a memory care unit. R1 and R2 identified with wandering, elopement behaviors, and left the facility without staff being aware of where they were.

Inspectors wroteBased on observation, interview and document review the facility failed to demonstrate safe patient handling to reduce the risk for accidents for 3 of 4 residents (R1, R2, R3) reviewed for safety with mechanical lift assisted transfers.

Inspectors wroteBased on interview and document review, the facility failed to ensure sufficient staffing to provide routine and assessed needs for toileting for 2 of 2 residents (R3) who resided on the main level and (R41) who resided on the memory care unit. In addition, 2 of 3 family members (FM-A, FM-B) voiced concerns with inadequate number of staff to provide resident care/needs for (R37, R41). Further, 4 of 4 residents (R3, R14, R20, R30) and 5 of 5 staff members (NA-E, NA-H, NA-I, AD, LPN-A) voiced concerns with the lack of sufficient staff in the facility. This deficient practice had the potential to affect all 49 residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident council with responses, actions, and rationale taken regarding their concerns 4 of 4 (R14, R30. R20 and R3) resident council members in the facility. This deficient practice had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a clean and sanitary environment when a visibly soiled commode bucket was stored next to a night stand for 1 of 4 residents (R25) and soiled bedpans were left out for 2 of 4 residents (R3, R42) reviewed for environment. In addition, the facility failed to store ADL supplies in a clean and discreet manner for 2 of 4 residents (R16, R25). Further, the facility failed to maintain standing lifts shared by residents in a clean and sanitary manner.

Inspectors wroteBased on interview and document review, the facility failed to update the care plan for 3 of 3 residents (R42, R41 and R15) reviewed for discharge planning. In addition the facility failed to update the care plan for 1 of 1 residents (R37) reviewed for activities.

Inspectors wroteR42 R42's admission MDS dated [DATE], identified R42 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis, anxiety, and depression. Identified R42 was dependent on staff for oral cares, hygiene, dressing and bathing. R42's Identified R42 participated in goals and had an overall goal to discharge to the community at time of assessment. R42 had no active discharge plan and R42's expected discharge date was three or fewer months away. R42's Care Area Assessment (CAA) dated 12/22/24, identified R42 had a self-care performance deficit related to weakness. Identified R42's care plan would be completed for self-care deficit and impaired mobility and staff would assist with ADL completion. R42's care plan revised 1/13/25, identified R42 had an ADL self-care performance deficit related to weakness. [...]

Inspectors wroteR3 R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. R3's MDS also identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. R3's Functional Abilities Care Area Assessment (CAA) dated 9/19/24, identified R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. Staff would review and update care plan as needed. R3's care plan revised 12/16/24, identified R3 had an activities of daily living (ADL) self-care performance deficit related to immobility and related to amputation of one lower extremity. R3 required assistance of one for toilet use, personal hygiene, dressing and bathing. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R26) who utilized an indwelling catheter.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a complete and comprehensive assessment was completed for 1 of 1 residents (R16) reviewed for braces.

Inspectors wroteBased on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R26) reviewed for resident assessment.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R37) whose care plan was reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oral cares were performed for 1 of 3 residents (R42) who required assistance with hygiene, and were reviewed for activities of daily living (ADL). Findings Include: R42's admission Minimum Data Set (MDS) dated [DATE], identified R42 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis, anxiety and depression. Identified R42 was dependent on staff for oral cares, hygiene, dressing and bathing. R42's Care Area Assessment (CAA) dated 12/22/24, identified R42 had a self-care performance deficit related to weakness. Identified R42's care plan would be completed for self-care deficit and impaired mobility and staff would assist with ADL completion. R42's care plan revised 1/13/25, identified R42 had an ADL self-care performance deficit related to weakness. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R37) reviewed for activities.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance to ensure hearing aids were available to maintain hearing/communication needs for 1 of 1 resident (R3) reviewed for hearing. Findings Include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. Identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. Identified R3 had moderate difficulty with hearing, and used hearing aide or other hearing appliance. R3's Functional Abilities Care Area Assessment (CAA) dated 9/19/24, identified R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. [...]

Inspectors wroteBased on interview and document review, the facility failed to implement a system to ensure medications were available to administer as ordered for 1 of 1 residents (R14) identified who did not receive medications as ordered.

Inspectors wroteBased on observation, interview and document review, the facility had a 6.25% percent medication error rate for 1 of 7 residents (R14) observed during medication administration.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R5, R44, and R46) were offered or received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure all three years of survey results were readily accessible for residents or visitors. This deficient practice had the potential to affect all 49 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dignity was maintained for 1 of 3 residents (R1) who had unwanted facial hair present, reviewed for dignity. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, and had diagnoses which included: hypertension, diabetes mellitus, respiratory failure, and fracture in past six months. Indicated R1 was dependent on staff for transfers, dressing and personal hygiene, which included shaving. R1's Care Area Assessment (CAA) dated 12/20/24, identified R1 had an activities of daily living (ADL) self-care performance deficit related to (r/t) collapsed vertebra, and was working with therapy. Indicated R1's care plan for self-care deficit and impaired physical mobility would be completed. Staff would assist with ADL completion and encourage self-participation. [...]

Inspectors wroteBased on interview, and document review, the facility failed to ensure an allegation of employee to resident abuse was immediately reported no later than two hours, to the State agency (SA) for 1 of 3 residents (R4) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to submit to the State Agency (SA) the results of the investigation within 5 working days for 1 of 3 residents (R4) reviewed for abuse, for 1 of 1 allegations of abuse reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident call light was within reach for 1 of 4 residents (R3) reviewed for call light accessibility. Findings Include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact, and had diagnoses which include: anxiety, depression, and asthma (a condition that affects airways and makes breathing difficult). Indicated R3 was dependent on staff for rolling left and right, transfers, dressing and hygiene. R3's Care Area Assessment (CAA) dated 8/23/24, identified R3 had chronic pain related to low back pain, neuropathy (condition that affects the nerves outside brain and spinal cord) and history of fusion of lumbosacral region ( surgical joining of vertebrae to the lower back area of spine). R3 took Lyrica (medication used to treat nerve pain) for pain management. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure adequate supervision was provided for 1 of 3 residents (R2) reviewed, who required supervision while eating due to assessed choking risk.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the residents received the prescribed diet, as ordered, for 1 of 2 residents (R2) reviewed for mechanically altered diets.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate hand hygiene was performed while assisting with toileting cares for 1 of 1 residents (R3) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor for healing and complete neuro checks for 1 of 3 residents (R1), who rolled off the bed and sustained a scalp hematoma and traumatic hematoma of forehead.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow plan of care for bed mobility and incontinence cares for 1 of 3 residents (R1) reviewed for accidents, when R1 rolled off the bed and sustained a scalp hematoma and traumatic hematoma of forehead and was sent to the emergency department (ED) for a CT scan with negative results.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow enhanced barrier precautions while providing high contact direct care for 1 of 2 (R1) residents reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. In addition, the facility failed to ensure dishes were sanitized when dishwashing temps were not reaching the required temperatures. Further, the facility failed to ensure staff were wearing proper hair restraints such as hair and beard nets and ensure safe delivery of beverages during dining observation. This deficient practice had the potential to affect all 45 residents who received food and beverages from the refrigerators and freezers.

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on the facility specific QAPI (Quality Assurance and Performance Improvement) program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program.

Inspectors wroteBased on observation, interview and document review, the facility failed to store tube feeding and suctioning supplies in a clean and sanitary manner for 1 of 1 residents (R7) whose supplies were left sitting out. In addition, the facility failed to maintain standing lifts shared by residents in a clean and sanitary manner.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R34) who was observed to self administer a nebulizer and had not been assessed as safe to self administer medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure adequate supervision was provided, an accurate assessment was completed and smoking interventions were implemented to reduce the risk of avoidable injuries for 1 of 1 resident (R4) who reviewed for smoking.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure administration of tube feeding formula according to physician's orders for 1 of 1 residents (R43) reviewed for tube feeding.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide oxygen therapy as ordered by the physician for 1 of 1 resident (R14) who utilized oxygen to maintain adequate oxygen saturation levels.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 1 of 5 hallways observed for linen transportation.

Inspectors wroteBased on interview and document review, the facility failed to ensure the State agency (SA) was notified as required when the current director of nursing (DON) was appointed to their position. This deficient practice had the potential to affect all 45 residents in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents received the prescribed diets as ordered for 3 or 3 residents (R1, R4 and R7) reviewed for therapeutic diets.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure non-pressure related wounds were monitored for signs and symptoms of infection and healing until resolved for 3 of 3 residents (R1, R2, R3) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure R19's responsible party was notified of a change of condition in a timely manner for 1 of 1 residents (R19) reviewed for change of condition who developed symptoms of short of breath (SOB), abnormal lung sounds, low oxygen saturations and was transferred to the emergency room (ER).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 2 residents( R18) reviewed for activities of daily living (ADL)'s.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R1, R2, R26) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations.