Fair Oaks Rehab & Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's insulin was administered as ordered for 1 of 3 residents (R1) reviewed for medications in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident experiencing nausea and loose stools during a salmonella outbreak was considered for salmonella infection. This failure resulted in R6 experiencing loose stools with nausea for a week before being sent to the local hospital for salmonella and sepsis. This applies to 1 of 6 residents reviewed for infection control in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a cognitively impaired resident (R7) from sexual abuse by another resident with a known pattern of sexually inappropriate behaviors. R8 was observed with his hand on R7's thigh moving towards her genital area. This failure applies to two of three residents (R7, R8) reviewed for abuse in the sample of 8 and resulted in Immediate Jeopardy. The Immediate Jeopardy began on 3/2/2026 when R8 was observed with his hand on R7's lap moving up towards her private area. V1 (Administrator) was notified of the Immediate Jeopardy on 3/5/2026 at 3:18 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 3/6/2026, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have isolation signs on the doors of two residents on isolation. This applies to 2 of 3 residents (R2,R3) reviewed for infection control in the sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform incontinence care for a dependent resident (R3). This applies to 1 of 3 residents reviewed for incontinence care in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's need for siderails for positioning/bed mobility before removing them for 4 of 16 residents (R47, R42, R26 and R23) reviewed for accommodation of need in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pureed meal was prepared in a smooth consistency. This applies to 6 of 6 residents (R49, R56, R65, R20, R33, R42) reviewed for therapeutic diets in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed to be able to self-administer medications. This applies to 1 of 16 residents (R50) reviewed for medication self-administration in a sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Stage III pressure wound was assessed for 1 of 4 residents (R1) reviewed for pressure wounds in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement nutritional interventions for a resident who is underweight for 1 of 5 residents (R12) reviewed for nutrition in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received pain medication as ordered to achieve adequate pain control for 1 of 16 residents (R60) reviewed for pain management in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 16 residents (R46) ingested their medications in the sample of 16 residents reviewed for pharmacy services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy recommendations were addressed and/or implemented for 1 of 5 (R23) residents reviewed for monthly medication review in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered at the correct time and the correct location. There were 47 opportunities with 7 errors resulting in a 14.89% error rate. This applies to 2 of 4 residents (R23 and R64) observed in the medication pass.1. R64's Face Sheet shows diagnoses of: generalized osteoarthritis, diabetes mellitus, and hypertension. R64's September Medication Administration Record shows orders for: Lidocaine External Patch 4%-Apply to right elbow one time a day for right elbow pain to be applied at 8:00 AM, Vitamin D3 10 MCG (micrograms)-2 tablets by mouth one time daily at 8:00 AM, labetalol 100 MG (milligrams)-1 tablet by mouth twice daily at 8:00 AM and 8:00 PM for hypertension, and Insulin Lispro-inject per sliding scale subcutaneously with meals at 8:00 AM, 12:00 PM and 5:00 PM for diabetes mellitus. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Personal Protective Equipment (PPE) was used when providing care to residents on contact isolation or enhanced barrier precautions to prevent the spread of infections for 2 of 16 residents (R8 and R63) reviewed for infection control in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors. This applies to 2 of 3 residents (R1, R2) reviewed for medications in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident (R9) found not breathing and pulseless whose physician's order showed the resident was a Full Code. This failure led to a delay in R9 receiving CPR and R9 dying in the facility. This applies to 1 of 3 residents (R9) reviewed for death in the sample of 14. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:40 PM, when facility staff failed to immediately initiate CPR on R9 when she was found unresponsive and pulseless. This failure resulted in R9 receiving CPR 42 minutes after being found unresponsive and pulseless, which resulted in R9 dying in the facility on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:13 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor a change of condition for a resident following surgical repair of left humerus fracture. This failure resulted in R1 sustaining a new fracture to her left distal humerus shaft discovered on her outpatient appointment on 1/29/25 (nine days after admission) and requiring new surgical intervention. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to maintain reconciliation of a controlled narcotic medication. This failure has the potential to affect all 14 residents (R1-R14) that reside in the facility and have a current order for the narcotic. This past non compliance occured from October 25, 2024-November 5, 2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide R5 with incontinence care to prevent the saturation of her outer clothing for 1 of 5 residents (R5) reviewed for activities of daily living care for dependent residents in the sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow R3's dietary care plan for food preferences for 1 of 3 residents (R3) in the sample of 8.

Inspectors wroteBased on interview and record review, the facility staff failed to immediately notify the Administrator (Abuse Coordinator) of an allegation of physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to perform COVID-19 testing after an exposure to a positive health care worker which applies to 5 of 5 residents (R13, R15, R16, R19, R33) reviewed for infection control in a sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure a treatment dressing was in place for a resident with stage 2 coccyx pressure injury, and failed to ensure pressure relieving interventions were in place for a resident at risk for developing pressure injuries. This applies to 2 of 4 residents (R19, R12) reviewed for pressure ulcers in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion for a resident with left sided weakness and pain, failed to have a restorative nurse to monitor restorative interventions, and failed to ensure an ordered splint was in place for a resident with contractures. This applies to 2 of 4 residents reviewed for restorative interventions in a sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional interventions were provided for a resident with weight loss. This applies to 1 of 6 (R33) residents reviewed for weight loss in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccinations were offered which applies to 3 of 5 residents (R13, R19, R33) reviewed for immunizations in a sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received their ordered dose of insulin for 1 of 3 residents (R1) reviewed for insulin administration in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a CNA (Certified Nursing Assistant) assisted and supervised a resident in the shower room. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a Water Management Program to reduce the risk of Legionella growth for all the residents residing in the facility failed to wear gowns during resident care for a resident on Enhanced Barrier Precautions; and failed to place a nasal cannula in a manner to prevent cross-contamination (R9). These failrues have the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide direct care in a dignified manner for 1 of 2 residents (R9) reviewed for dignity in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care in a manner to prevent cross-contamination, and failed to provide wound care as ordered by the physician. This applies to 1 of 2 (R11) residents reviewed for non-pressure injury wound care in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent skin breakdown, and failed to identify and assess a Stage 2 pressure ulcer for 2 of 4 residents (R9 & R26) reviewed for pressure ulcers in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly perform indwelling catheter care for 1 of 1 residents (R9) reviewed for catheter care in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the correct dose of oxygen, failed to ensure nasal cannulas were not laying on the floor, failed to clean air filters on oxygen concentrators and a humidification container on an oxygen concentrator that was full and working, and failed to ensure a resident with CPAP (continuous positive airway pressure) had a head strap and nasal pillow/mask that fit. This applies to 2 of 4 residents (R26 & R34) reviewed for oxygen therapy in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received the correct dosage of medication for 1 of 1 residents (R34) reviewed for medications in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow manufacturer instructions regarding the use of the three compartment sanitization sink. This applies to 2 of 2 residents (R17 & R30) reviewed for sanitization in the sample of 17.