Fair Oaks Lodge

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 20, 2025

  Based on observation, interview and document review the facility failed to ensure safe transport with a facility van for 1 of 3 residents (R1). This resulted in an immediate jeopardy (IJ) for R1 when she slid out of wheelchair during transport, resulting in fractures. The immediate jeopardy (IJ) began on 6/11/25, at approximately 10:00 a.m., when the transport driver (TD) transported R1 in the facility van without the use of a seatbelt. R1 slid out of her wheelchair during transport resulting in closed fractures to the right and left tibias (the larger bone of the lower leg) and closed fracture of left femur (the main bone in your thigh that connects your hip to your knee and is your body's largest and strongest bone). […]

• Immediate jeopardy, isolatedF578Sep 27, 2023

  Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the residents' current wishes which affected 1 of 43 residents (R34) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R34 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R20's electronic health record (EHR) banner and orders identified R34 was to have CPR however, R34's updated physician's order for life sustaining treatment (POLST) signed on ,d+[DATE]//23, identified R34's wishes of do not resuscitate (DNR). […]

• Immediate jeopardy, isolatedF689Feb 23, 2022

  Based on interviews and document review, the facility failed provide adequate supervision 1 of 3 residents (R1), who resided on the memory care unit and was identified as an elopement risk, was able to leave the facility during freezing temperatures. This result in an immediate Jeopardy. The immediate jeopardy began on 2/14/22, when R1, who exhibited wandering and exit seeking behaviors, was able to leave the memory care unit and exit the facility during freezing temperatures ( zero to two degrees Fahrenheit) which was identified on 2/23/22. The interim administrator and director of nursing (DON) were notified of the immediate jeopardy at 6:07 p.m. on 2/23/22. […]

• No harm, potential for more than minimal, widespreadF725Feb 12, 2025

  Based on interview and document review, the facility failed to ensure sufficient staffing to provide routine and assessed needs for toileting for 2 of 2 residents (R3) who resided on the main level and (R41) who resided on the memory care unit. In addition, 2 of 3 family members (FM-A, FM-B) voiced concerns with inadequate number of staff to provide resident care/needs for (R37, R41). Further, 4 of 4 residents (R3, R14, R20, R30) and 5 of 5 staff members (NA-E, NA-H, NA-I, AD, LPN-A) voiced concerns with the lack of sufficient staff in the facility. This deficient practice had the potential to affect all 49 residents who resided in the facility. […]

• No harm, potential for more than minimal, widespreadF812Jun 27, 2024

  Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. In addition, the facility failed to ensure dishes were sanitized when dishwashing temps were not reaching the required temperatures. Further, the facility failed to ensure staff were wearing proper hair restraints such as hair and beard nets and ensure safe delivery of beverages during dining observation. This deficient practice had the potential to affect all 45 residents who received food and beverages from the refrigerators and freezers. […]