Fair Oaks Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 6, 2024

  Based on observation, interviews, and record review the facility failed to ensure the safety for one resident (Resident 1) when Resident 1 did not receive adequate supervision and assistance during breakfast. This failure resulted in burns and blisters to two of Resident 1's fingers and pain to the affected area. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in May 2020 with diagnoses which included parkinsonism (brain conditions that cause tremors) and ataxia (loss of muscle control in arms and/or legs). A review of a nurse progress note dated 4/22/24 at 2:33 p.m. indicated, [Resident 1] was attempting to feed self this AM [morning] without CNA assistance. […]

• Actual harm, isolatedF687Mar 21, 2024

  Based on interview and record review, the facility failed to ensure one resident (Resident 1) out of three sampled residents received proper foot care when: 1. Lack of documentation indicating Resident 1's wound on the right foot second toe was being assessed per nursing standards; and 2. Transportation services were not provided to Resident 1's podiatry (the medical care and treatment of the human foot) appointments. These failures resulted in Resident 1 not receiving foot care per nursing standards which led to a partial right foot amputation (surgical removal of part of the body). […]

• No harm, potential for more than minimal, widespreadF882Mar 21, 2024

  Based on interview and record review, the facility failed to ensure an Infection Preventionist (IP: a nurse responsible for the facility's Infection Prevention and Control Plan) was available to meet all the requirements of the position for a census of 141 residents. This failure decreased the facility's potential to prevent the spread of infection among staff and residents. Findings: An interview on 3/1/24 at 9:10 a.m., the Executive Director (ADM) stated the facility's full time IP left in January 2024 and indicated the IP continued to work part-time during February 2024. […]

• No harm, potential for more than minimal, widespreadF607Feb 8, 2024

  Based on interview and record review, the facility failed to implement policies and procedures for the prohibition and prevention of abuse for a census of 142 residents when 22 out of 26 sampled facility staff hired in December 2023 (Certified Nurse Assistant [CNA] 3, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, CNA 16, CNA 17, CNA 18, CNA 19, CNA 20, CNA 21, Licensed Nurse [LN] 4, LN 5, and Housekeeping Staff [HKS]) started working with residents in the facility without an employee background check (a formal process that verifies an upcoming employee's personal and professional information such as identity, work history, criminal record, and any other relevant information) done. […]

• No harm, potential for more than minimal, patternF585Feb 13, 2026

  Based on interview and record review, the facility failed to promptly act upon identified concern and request for a room change for one of 34 sampled residents (Resident 151), when the facility failed to honor and address Resident 151's power of attorney (POA, a person designated to make decisions) request to transfer Resident 151 to a different room.This failure had the potential to contribute to Resident 151's inability to rest and sleep and had the potential to affect Resident 151's emotional well-being and quality of life.A review of the admission record indicated the facility admitted Resident 151 in January of 2026 with multiple diagnoses which included Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and the ability to… […]