Fair Park Health & Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four of eighteen residents (Residents #2, #19, #30, and #35) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident Residents #2, #19, #30, and #35's rooms were in a position that was accessible to the residents on 07/08/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for five of twenty residents (Residents #2, #6, #12, #21, and #49) reviewed for privacy and confidentiality. 1. The facility failed to ensure Residents #12, #21, and #49's personal medical information was secured on 07/09/2026. 2. The facility failed to ensure LVN B closed the door or pulled the privacy curtain while checking Resident #2's blood sugar and administering his insulin on 07/09/2026. 3. The facility failed to ensure LVN B closed the door or pulled the privacy curtain while checking Resident #6's blood sugar on 07/09/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents' environment remained free of hazards as was possible for three of eight residents (Residents # 6, #38, #45) and two direct care staff (LVN A and WCN E) reviewed for accident hazard. 1. The facility failed to ensure there was no razor inside Resident #6's room on 07/08/2026. 2. The facility failed to ensure there was no cleaner disinfectant inside Resident #45's room on 07/08/2026. 3. The facility failed to ensure WCN E did not leave her scissors, unattended, inside Resident #38's room on 07/09/2026. 4. The facility failed to ensure there was no germicidal wipes on top of a cart parked in the hallway, unattended, on 07/08/2026. 5. The facility failed to ensure a container of germicidal wipes was not left at the nurse station unattended on 07/09/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of eighteen residents (Residents #8, #15, #38, #45, and #47) reviewed for medication storage. 1. The facility failed to ensure that there was no medication for hemorrhoids inside Resident #8's room on 07/08/2026. 2. The facility failed to ensure that there was no laxative solution inside Resident #15's room on 07/08/2026. 3. The facility failed to ensure that there was no nasal spray inside Resident #47's room on 07/08/2026. 4. The facility failed to ensure that there were no eye drops, calcium alginate powder, and wound cleanser inside Resident #45's room on 07/08/2026. 5. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in kitchen was dated and discarded prior to their use-by date and were properly sealed. This failure could place residents at risk for food contamination and food-borne illness. During an observation on 07/08/2026 between 9:05 AM and 9:39 AM in the facility's kitchen revealed: One gallon bag containing Cookie pieces dated 05/01/2025 expiration date 09/01/2025. One gallon bag of cake mix dated 04/07/2026 with an expiration date of 05/07/2026. One large plastic bag containing ketchup with no visible dates. One container of all-vegetable shortening 02/14/2022 best buy date of 12/25/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of eighteen residents (Residents #11, #19, #31, and #33) reviewed for infection control. 1. The facility failed to ensure CNA C performed hand hygiene during Resident #31's incontinent care on 07/08/2026. 2. The facility failed to ensure MA G performed hand hygiene when preparing medications for Residents #11, #19, and #33 on 07/09/2026. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care to one of eight residents (Resident #47) reviewed for baseline care plan. The facility failed to ensure Resident #47 had a baseline care plan for atelectasis after admission to the facility on [DATE]. This failure could place the resident at risk of not receiving necessary care, treatment, and services upon admission that could result in worsening conditions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of eight residents (Resident #47) reviewed for care plans. The facility failed to ensure that Resident #47 had a care plan for her acute upper respiratory infection on 07/09/2026. This failure could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for two of twelve residents (Residents #12 and Resident #29) reviewed for care plans revision. The facility failed to ensure the care plans for Residents #12 and Resident #29 were reviewed and revised after each comprehensive and quarterly assessment. This failure could place the residents at risk of care and needs not being met.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of five residents (Resident #45) reviewed for catheter care. The facility failed to ensure Resident #45's catheter bag was off the floor on 07/08/2026. This failure could place the residents at risk of urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of ten residents (Residents #47) reviewed for respiratory care. The facility failed to ensure Resident #47's breathing mask was properly stored when not in use on 07/08/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident was free from abuse, neglect and corporal punishment of any type by anyone one of four residents (Resident #1) reviewed for abuse. PTA M reported and observed Resident #2 hitting Resident #1 while in the smoking area on 04/09/26. This failure could place residents at risk of sustaining serious harm and not being free from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 2 of 3 residents (Residents #1 and #2) reviewed for clinical records regarding wound care.1. The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #1 for a skin tear on her left buttocks on 03/06/26, 03/07/26, 03/08/26, 03/14/26, and 03/15/26 and for a post-surgical wound on her abdomen on 03/06/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/20/26, 03/21/26, 03/28/26 and 03/30/26. 2. The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #2 on 03/10/26, 03/20/26, 03/27/26, 03/28/26, 03/29/26. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 Residents (Resident #1, and Resident #2) observed for infection control. 1. The facility failed to ensure CNA D and RN A utilized Enhanced Barrier Precautions and performed hand hygiene during wound care for Resident #1 on 02/21/26. 2. The facility failed to ensure RN A handled Resident #1's wound care supplies appropriately to prevent cross contamination during wound care on 02/21/26. 3. The facility failed to ensure LVN B performed hand hygiene during wound care for Resident # 2 and failed to prevent cross contamination of wound care supplies on 02/21/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, easy to use, clean and comfortable environment for 4 of 10 resident rooms on the 100 - hall (Resident rooms #1, #2, #3, and #4). The facility failed to ensure Resident rooms #1, #2, #3, and #4, were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident is being watched and has assistance devices, when needed, to prevent accidents for six of nine residents (Resident #4, #5, #6, #7, #8, and #9) reviewed for accident hazards. The facility failed to ensure Resident #4, #5, #6, #7, #8, and #9 were properly supervised while smoking in the smoking area of the facility. This failure could place the residents at risk of harm and serious injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of three residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's nasal canula was properly stored in a bag when not in use on 09/23/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident's room for two of five residents (Resident #1, and #3) reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #1, and #3's room was in a position that was accessible to the residents on 09/23/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two (Resident #1 and Resident #2) of two reviewed for abuse and neglect. The facility failed to ensure Resident #2 was free from abuse, on 6/27/25, when Resident #1 struck her in the forehead with a cane, which resulted in a laceration. This failure could place residents at risk of abuse and emotional stress.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #4) of 5W residents reviewed for PASARR. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal 02/20/2025 as required within 20 business days after the date of the Interdisciplinary Team meeting . The NFSS Request submittal by the NF was denied on 02/10/2025, and there was no evidence of facility follow up. to ensure the request was approved to provide specialized services for PASARR for the resident. These failures could place the resident at risk of not receiving necessary care and/or services. Findings Included: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech -language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 1 (Resident #4) of 5 residents reviewed for specialized rehabilitative services. The facility failed to ensure Resident #4 received physical therapy per the PASARR Comprehensive Service Plan January 2025 to April 2025 . This failure could place residents who require specialized rehabilitative services at risk of a decline in health status and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 1 of 2 medication carts (Unit 2) reviewed for drug storage. On 05/13/2025, LVN D left the Unit 2 medication cart unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 05/12/25. 2. The facility failed to ensure an expired item in the dry storage pantry area was removed on 05/12/25. 3. The facility failed to ensure the dented cans in the dry storage area with the other canned food were removed from the shelf on 05/12/25. 4. The facility failed to clean the 6 A/C vents in the kitchen on 05/12/25. These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one of (Resident #43) of two residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #43 when he planned discharge home on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #22) reviewed for ADL care. CNA G failed to ensure Resident #22 was provided her shower as scheduled on the 2:00 PM to 10:00 PM shift on 5/12/25. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of five (Resident #22) residents reviewed for pharmacy services. The Facility failed to ensure nursing staff ordered medications in a timely manner for Resident #22 resulting in her missing a scheduled morning dose of Robaxin used to control her muscle spasms on 5/13/25. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice for 2 (Resident #1 and #4) of 4 residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #1's nasal cannula, for the oxygen concentrator, was placed in a sanitary container when not in use. 2. The facility failed to ensure that Resident #4's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) was changed. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 (Resident #2) of 3 residents reviewed for accident prevention. The facility failed to ensure Resident #2's bed was placed in the lowest position to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident when 1 (Resident #3) of 6 residents were reviewed for pharmaceutical services. The facility failed to ensure that Resident #3 did not miss doses of medication that was to be administered at bedtime. This failure could place residents at risk of not receiving their medications as ordered by their physician.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure refrigerator items were dated and labeled. 2. The facility failed to ensure ice scoop was left outside of ice bin. 3. The facility failed to ensure [NAME] A performed hand hygiene during lunch meal service on 4/4/24. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #19, Resident #22) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #19 had her fingernails cleaned and trimmed. 2- Resident #22 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Residents #25) of one resident reviewed for feeding tubes in that: LVN B failed to check placement of Resident #25's G-Tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) by checking for gastric residual (quantity remaining) prior to administering the resident medications. This failure could affect residents by placing them at risk of obstruction of the G-tube, nausea, vomiting and potential for aspiration and discomfort.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 (Resident #23) reviewed for respiratory care, in that: The facility failed to ensure Resident #23 Oxygen humidity bottle were labeled or dated. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #10) of 8 observed for infection control. The facility failed to ensure RN C performed hand hygiene and changed gloves during wound care for Resident #10. This failure could place residents at risk for infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 3 residents reviewed for infection. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review revealed the facility failed to make prompt efforts to resolve grievances for 1 of 5 residents (Resident #1) whose records were reviewed for grievances. The facility failed to document, investigate, and respond to Resident#1's family member/visitor's complaint communicated to the Administrator. This deficient practice could contribute to the resident's frustration and feelings of hopelessness.