Fair Oaks Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Fair Oaks Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF656Jan 5, 2022

  Based on observation, interview, record review and review of facility policy, it was determined the facility failed to implement the plan of care for one (1) of thirteen (13) sampled resident's, Resident #1. Review of Resident #1's medical record revealed the resident had been care planned for Activities of Daily Living (ADL) which included an intervention for staff to use a mechanical lift with a small sling for his/her transfer needs. However, on 11/15/2021 staff utilized a mechanical lift and transferred Resident #1 from the bed to a reclined geri-chair (medical chair that reclines), which staff failed to lock in place. […]

• Actual harm, isolatedF689Jan 5, 2022

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible and residents received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents, Resident #1, who were transferred with a mechanical lift out of a total sample of thirteen (13) residents. On 11/15/2021, staff used a mechanical lift to transfer Resident #1 from the bed to a reclined geri-chair (specialized reclining chair). […]

• No harm, potential for more than minimal, widespreadF727Apr 30, 2026

  Based on interview, and review of facility documentation, the facility failed to ensure the Director of Nursing (DON) was not assigned to work as a floor nurse when the facility had an average daily census of more than 60 residents, which had the potential to affect all residents in the facility.The findings include: In interview on 04/30/2026 at 12:15 PM, the Administrator stated the facility did not have a policy related to the DON working as a floor nurse when the average daily census was more than 60 residents. […]

• No harm, potential for more than minimal, patternF689May 11, 2022

  Based on observation, interview, record review and review of facility policy it was determined the facility failed to provide adequate supervision to prevent resident to resident incidents for four (4) of eight (8) sampled residents, Resident #1, Resident #2, Resident #5, and Resident #7. Review of Resident #1's medical record, and interviews with staff and Resident #7, revealed Resident #1 exhibited behaviors of wandering into other residents' rooms, making sexually inappropriate comments, getting into bed with another resident and touching other residents on their leg and buttock. […]

• No harm, potential for more than minimal, patternF600Jan 5, 2022

  Based on observation, interview, record review, review of the facility's policy and investigations, it was determined the facility failed to ensure residents were protected from abuse for five (5) of thirteen (13) sampled residents (Resident #4, #5, #6, #7 and #8). Interview and record review revealed Resident #4 exhibited unpredictable aggressive behaviors towards other residents and staff and wandered in and out of other residents' rooms. However, the facility failed to implement effective interventions to prevent Resident #4 from displaying aggressive behaviors towards other residents, which resulted in four (4) resident to resident incidents between 06/02/2021 and 11/16/2021, a five (5) month timeframe. […]