Fair Oaks Health & Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Feb 5, 2025

  4. For Resident #132 (R132), a resident with a wound, the facility staff failed to implement enhanced barrier precautions (1). A review of R132's clinical record revealed a physician's order dated 12/27/24 that documented to cleanse the resident's sacral wound with normal saline, pat dry, apply calcium alginate and cover with a foam border dressing every day shift. Further review of R132's clinical record failed to reveal a physician's order for enhanced barrier precautions. On 2/4/25 at 10:11 a.m., an observation of LPN (licensed practical nurse) #4 changing a dressing on R132's sacrum was conducted. LPN #4 wore gloves during the dressing change but did not wear a gown. […]

• No harm, potential for more than minimal, widespreadF814Apr 8, 2021

  Based on observation, staff interview and facility document review, it was determined the facility staff failed to maintain the dumpster area in a sanitary manner to prevent pests. Approximately four clear gloves were noted on the ground around the dumpsters and bits of paper trash was observed on the ground throughout the area around the dumpsters The findings include: Observation was made of the dumpster area on 4/7/2021 at 8:49 a.m. accompanied by other staff member (OSM) #7, the dietary manager. There were three metal dumpsters. One for cardboard and two for trash. Approximately four clear gloves were noted on the ground around the dumpsters. When asked which department uses the clear gloves, OSM #7 stated that they are used throughout the facility. […]

• No harm, potential for more than minimal, patternF658Oct 8, 2025

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify a physician of a resident's blood sugar level according to the physician's order for one of 11 residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), the facility staff failed to notify the physician when the resident's blood sugar was greater than 200 on multiple occasions in June 2025.A review of R3's clinical record revealed the following physician order dated 6/18/25: Blood glucose checks ac and hs before meals and at bedtime for DM (diabetes mellitus). […]

• No harm, potential for more than minimal, patternF684Oct 8, 2025

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement physicians' orders for three of 11 residents in the survey sample, Residents #6, #3, and #8.The findings include:1. For Resident #6 (R6), the facility staff failed to administer Lantus (long acting insulin) according to the physician's order during a medication administration observation on 10/7/25. On 10/7/25 at 8:03 a.m., RN (registered nurse) #2 was observed preparing insulin for administration to R6. RN #2 prepared the injector pen of Lantus (long acting insulin) by turning the dial to 10. RN #2 confirmed that R6 was to receive 10 units of Lantus to R6. […]

• No harm, potential for more than minimal, patternF550Feb 5, 2025

  3. For Resident #147 (R147), the facility staff failed to dress the resident in clothes prior to the resident sitting in a common area. R147 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/22/25, the resident scored 2 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. On 2/3/25 at 11:54 a.m. and 3:48 p.m., R147 was observed sitting in the day room. The resident was dressed in a gown and slipper socks. On 2/4/25 at 3:02 p.m., an interview was conducted with CNA (certified nursing assistant) #3 (the CNA caring for R147). CNA #3 stated residents should be dressed in clothes every day. […]