Fair Oaks Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 2, 2026

  Based on observation, interview, and record review the facility failed to ensure a resident was transferred with a mechanical lift in a safe manner which applies to 1 of 5 residents (R1) reviewed for safe transfers in a sample of 5. This failure resulted in R1 falling from a mechanical lift sling sustaining a subdural hematoma. This past compliance occurred from 1/23/26 to 1/29/25.The findings include:R1's undated Facesheet showed R1 is a [AGE] year-old female admitted to the facility on [DATE]. This Factsheet showed R1 was readmitted to the facility on [DATE] with a new diagnosis of traumatic subdural hematoma.The facility's State Agency Serious Injury Report dated 1/23/26 showed R1 was hospitalized after falling from a mechanical lift sling. […]

• Actual harm, isolatedF689Oct 9, 2025

  Based on observation, interview, and record review the facility failed to perform a safe wheelchair transport for a high fall risk resident for 1 of 3 residents (R1) reviewed for safety in the sample of 4. This failure resulted in R1 falling forward from the wheelchair and sustaining a broken nose and a laceration to his forehead that required sutures.Findings Include:On 10/9/25 at 10:10 AM, V9 (Certified Nursing Assistant -CNA/Restorative Aide) pushed R1 in his wheelchair from the dining room to a seating room without footrests in place. R1's shoes came in contact with the floor four times during the transport of approximately 25 feet. R1 was well groomed with a bandage on the middle of his forehead. R1 had a privacy bag for his indwelling catheter directly under the seat of his chair. […]

• No harm, potential for more than minimal, widespreadF812Jun 8, 2022

  Based on observation, interview, and record review the facility failed to ensure the dishwasher was sanitizing dishes, failed to label and date food in the freezer, and failed to ensure staff was wearing hair nets, for all 37 residents residing in the facility. The findings include: The CMS 672 Form dated 6/6/22 shows a resident census of 37. 1. On 06/06/22 at 9:20 AM, V7 dietary aid was running the dishwasher, loading the breakfast dishes. V7 stated she doesn't usually run the dishwasher and does not know how to test the sanitation. V4 Cook tested the dishwasher chlorine sanitation level and it measured less than 50 PPM (Parts Per Million). V4 stated I usually check this in the morning. I checked this morning, and it was ok. You want it between 50 and 100 PPM. […]

• No harm, potential for more than minimal, patternF803Jun 6, 2024

  Based on observation, interview, and record review the facility failed to provide the correct portion of vegetables. This applies to 5 of 5 residents (R17, R21, R4, R6, & R11) reviewed for menus in the sample of 12 and 3 residents (R16, R1, & R80) outside the sample. The findings include: On 6/4/24 at 11:50 AM, V4 [NAME] began the noon lunch service for the dining room nearest the kitchen. V4 served sloppy joes, peas with onions, sweet potato, and cake. V4 used a green handled ice cream scoop to serve the peas and the portion appeared inadequate. On 6/4/24 at 12:18 PM, V4 completed the lunch service for the dining room adjacent to the kitchen. V4 stated the green handled ice cream scoop was 2.66 ounces. V4 stated the grey scoop is 4 ounces. […]

• No harm, potential for more than minimal, patternF812Jun 6, 2024

  Based on observation, interview, and record review the facility failed to measure food temperature on the steam table in a manner to prevent cross-contamination. This applies to 5 of 5 residents (R17, R21, R4, R6, & R11) reviewed for menus in the sample of 12 and 3 residents (R16, R1, & R80) outside the sample. The findings include: On 6/4/24 at 11:50 AM, V4 began the lunch service for the dining room adjacent to the kitchen. V4 stated he had already measured the temperature of the sloppy joe meat; however, it was requested he check the temperature again. V4 removed a thermometer from a cup that contained numerous writing utensils. V4 then stuck the thermometer probe into the sloppy joe meat without sanitizing the thermometer. […]