Fairway Oaks Center

Inspectors wroteBased on observations interviews and record review, the facility failed to ensure dependent residents received assistance with showers for three residents (#4, #3 and #2) out of four residents reviewed.

Inspectors wroteBased on record reviews and interviews the facility failed to maintain complete and accurately documented medical records for one (#2) of four sampled residents related to not completing the Admission/readmission evaluation in a timely manner, not completing a daily note for a resident receiving specialized services and skilled nursing.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure one (#2) of four residents received treatment and care in accordance with professional standards of nursing, physician orders, and person-centered care plan.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure outside resources were available for two residents (#4 and #3) out of two residents sampled, related to podiatry visit for Resident #4, and dermatology services for Resident #3.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities of daily living (ADLs) related to grooming and personal hygiene care for three dependent residents (#4, #6, and #7) out of three sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident representative was notified prior to the resident's transfer for one resident (#2) of three residents reviewed for discharge. Findings Included: Review of Resident #2's Minimum Data Set (MDS), with a target date of 7/23/25, Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 00. This BIMS score indicated severe cognitive impairment. The resident's representative was a family member. On 11/20/2025 at 12:51 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated there is no discharge note or documentation notifying the representative. She said consent was not provided by the representative. On 11/20/2025 at 1:31 p.m., an interview was conducted with the NHA. He confirmed he does not have any paperwork showing the representative gave consent. [...]

Inspectors wroteBased on record review, observations, and interviews the facility failed to maintain complete clinical records for one resident (#5) of five sampled residents which were accurately documented, readily accessible, and systematically organized.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of two community shower rooms were cleaned and maintained.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wheelchair mobility was provided for one (#7) of eight residents sampled. Finding Included: During multiple observations made on 09/08/2024, 09/09/2024, 09/10/2024 and 9/11/2024 at multiple times 10:00 a.m., 3:00 p.m., and 5:00 p.m., Resident #7 was observed lying down in bed with her call light within reach Review of an admission record showed Resident #7 was admitted to the facility with diagnoses which included but not limited to dysphagia following cerebral infarction, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance. Review of a Minimum Data Set, (MDS) dated [DATE] showed a Brief Interview for Mental Status, BIMS score of 00, which indicated interview was not able to be conducted. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide two (#76 and #82) of forty-six sampled residents with privacy during two of four days observed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure timely and accurate Pre-admission Screening and Resident Review (PASRR) for one (#73) of 23 sampled residents. Findings Included: 2. Review of the admission Record for Resident #73 showed the resident was initially admitted to the facility on [DATE] with a re-entry admission date of 03/04/2024. Admitting diagnoses included schizoaffective disorder bipolar type, major depressive disorder, dementia, mood disorder due to known physiological condition with depressive features. Review of Level I PASRR for Resident #73 dated 03/16/2022, revealed an incomplete PASRR with the qualifying diagnoses of depression, mood disorder and dementia not indicated. During an interview on 09/11/2024 at 9:45 a.m. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a care plan for one (#45) of six residents sampled for skin conditions and failed to develop and implement an Activities of Daily Living care plan for two ( #44 and #51) of five residents sampled. Finding Included: 1 During an observation made on 09/08/24 at 02:20 p.m., Resident # 45 was observed lying down in bed dressed in a hospital grown from the morning until late in the afternoon. The resident was trying to say something but was not able to communicate. On 09/09/2024 at 11:00 a.m., Resident # 45 was observed lying down in bed dressed in his hospital grown. Resident #45's legs was observed with scabs leaking with yellow fluid on his right and left legs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLs) for dependent residents which included performing fingernail care and showers for two (#44 and #51) of 46 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality care and services according to standards of practice related to medication administration and skin care treatment for one (#45) of three residents reviewed for wound care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide indwelling urinary catheter care and services to prevent leakage and breaks in tubing for two (#82 and #13) of ten sampled residents during two of two days observed (9/8/2024 and 9/9/2024).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure trauma informed care was provided for one (#39) of one resident with post-traumatic stress disorder (PTSD). The facility did not ensure PTSD triggers were on Resident #39's care plan. The facility did not ensure staff was trained annually on trauma informed care as the facility policy indicated. Findings Included: Review of admission Record showed Resident #39 was initially admitted to the facility diagnoses which included major depressive disorder, schizoaffective disorder, unspecified psychosis, post-traumatic stress disorder, other specified persistent mood disorders, anxiety disorder, dementia. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE], Section C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents and visitors with up to date and correct daily staffing posting information. It was determined the facility had not updated this sheet for a total of three days.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5% for three (#14, #93, #498) of four sampled residents who were administered medications. This resulted in seven errors from 35 medication administration opportunities for a medication error rate of 20.00%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. the medical record contained accurate and complete documentation for three (#498, #93, #14) of 46 sampled residents related to bathing and for one (#51) of four sampled residents related to medication administration.

Inspectors wroteBased on record review and interview, the facility failed to provide Abuse/Neglect training to one (Staff X) of 10 employees reviewed. Findings Included: During an interview on 09/10/2024 4:30 p.m. the Director of Nursing (DON) stated Resident #100 had a lower BIMS score, and frequently wandered around the building. He stated on 03/14/2024 his Assistant Director or Nursing (ADON) and the Unit Manager (Staff G, Licensed Practical Nurse [LPN]), came and let him know that Resident #100's Resident Representative (RR) was reporting an allegation of neglect. The DON stated he went to Resident #100's room to speak with the family. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure all alleged violations of abuse to include physical restraints were reported to the State Survey Agency for 1 (#100) out of 23 residents sampled.

Inspectors wroteBased on a review of the Food Committee meeting minutes and the facility policy on Grievances/Complaints, Filing; interview with the Dietary Manager, and interview and observation of eight residents (#157, #160, #159, #158, #38, #15, #30, #72) at meals, the facility failed to resolve a concern related to receiving condiments at meals voiced at the Food Committee meeting.

Inspectors wroteBased on record review, observation, and interview, the facility failed to implement their Weight Assessment and Intervention Policy by developing a care plan relevant to weight loss and failed to implement the care plan that had been developed on 02/19/2021 and revised on 04/09/2021 and 03/14/2022, for one (Resident #20 ) of 48 sampled residents related to weight loss.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) tasks for residents who required assistance to address soiled fingernails for one (Resident #207) of three residents sampled for ADL care.

Inspectors wroteBased on observations, record review, and interview, the facility failed to assess scratches on a resident's shins for one (Resident #9) of two residents sampled for skin conditions.

Inspectors wroteBased on observations, record reviews, and interviews, the facility did not identify the specific behaviors to monitor related to the administration of psychotropic medications for two (Residents #1 and #9) of six residents sampled for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was below 5 % for three (Residents #35, #257, and #96) of four sampled residents who were observed during medication administration. This resulted in 8 errors from 31 medication administration opportunities for a medication error rate of 25.81%. Findings Included: 1. On 08/31/2022 at 8:47 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #35. Staff D prepared and administered the following medications: Brimonidine Tartrate 0.2% solution one drop in both eyes, multivitamin with mineral one tablet, Plavix 75 mg one tablet, Lisinopril 40 mg tablet, Duloxetine HCL capsule delayed release 60 mg, Spironolactone 25 mg one tablet, Timolol maleate solution 0.5% one drop into each eye, and Lasix 40 mg tablet one tablet. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide dental services to one (Resident #35) of three residents sampled for dentures. Findings Included: On 08/29/22 at 11:09 a.m., an interview was conducted with Resident #35 as she was observed edentulous when she opened her mouth. She stated, I had dentures, but it was years ago. She said when she was hospitalized about 4 or 5 years ago, I had to call an ambulance to pick me up. I wish I had taken my dentures with me. Resident #35 stated When I was in the hospital, they threw out everything in my apartment. My dentures and everything I owned. She denied having issues with chewing but if the meat, especially the pork chops, were dry it took a while to chew them. When asked, Resident #34 smiled broadly and stated, I would love dentures. She confirmed she would wear them if she had them. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that one (Resident #21) of 40 residents sampled for PASRR (Pre-admission Screen and Resident Review) compliance was accurately completed and referred to the appropriate authority for PASRR Level II evaluation and determination.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure two (Residents #6 and #28) of forty sampled residents received the necessary services to provide grooming and personal hygiene related to showers, nail care, and shaves.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure an accident free environment for one (Resident #56) of three residents sampled for accidents.

Inspectors wroteBased on record reviews, interviews, and observations the facility failed to assess eight (#6, #10, #11, #14, #18, #30, #45, and #73) out of forty sampled residents for the use of bed/side rails prior to their use, to obtain consent for their use from the resident or/and representative prior to their use, failed to obtain a physician order for their use, and to include the use of side rails in the resident's care plan.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement an effective Antibiotic Stewardship program related to the monitoring of antibiotic use of one (Resident #27) of one resident sampled for Transmission-based precautions.