Fair Oaks Rehab & Healthcare

In the surveyor’s words

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

• Immediate jeopardy, patternF880Apr 14, 2021

  Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering Person Under Investigation (PUI) resident rooms, having PPE available outside the resident rooms to prevent exposure COVID-19; failed to ensure staff were using PPE when entering a resident room on contact precautions; failed to disinfect a multi use glucometer; and failed to ensure staff performed glove exchange and hand hygiene between resident care. This has the potential to effect 9 of 18 residents (R40, R199, R200, R201, R17, R37, R46, R4, R6) reviewed for transmission based precautions. […]

• Immediate jeopardy, isolatedF600Mar 10, 2026

  Based on observation, interview, and record review, the facility failed to protect a cognitively impaired resident (R7) from sexual abuse by another resident with a known pattern of sexually inappropriate behaviors. R8 was observed with his hand on R7's thigh moving towards her genital area. This failure applies to two of three residents (R7, R8) reviewed for abuse in the sample of 8 and resulted in Immediate Jeopardy.The Immediate Jeopardy began on 3/2/2026 when R8 was observed with his hand on R7's lap moving up towards her private area. V1 (Administrator) was notified of the Immediate Jeopardy on 3/5/2026 at 3:18 PM. […]

• Immediate jeopardy, isolatedF678Feb 11, 2025

  Based on interview and record review, the facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident (R9) found not breathing and pulseless whose physician's order showed the resident was a Full Code. This failure led to a delay in R9 receiving CPR and R9 dying in the facility. This applies to 1 of 3 residents (R9) reviewed for death in the sample of 14. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:40 PM, when facility staff failed to immediately initiate CPR on R9 when she was found unresponsive and pulseless. This failure resulted in R9 receiving CPR 42 minutes after being found unresponsive and pulseless, which resulted in R9 dying in the facility on [DATE]. […]

• Actual harm, isolatedF684Apr 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident experiencing nausea and loose stools during a salmonella outbreak was considered for salmonella infection. This failure resulted in R6 experiencing loose stools with nausea for a week before being sent to the local hospital for salmonella and sepsis. This applies to 1 of 6 residents reviewed for infection control in the sample of 6.The findings include:Per email communications with V1 (Administrator) on 4/7/26, V1 stated R4 and R6 were roommates from 2/14/26 until 3/21/26, when R6 was discharged to the local hospital. […]

• Actual harm, isolatedF684Feb 11, 2025

  Based on interview and record review, the facility failed to assess and monitor a change of condition for a resident following surgical repair of left humerus fracture. This failure resulted in R1 sustaining a new fracture to her left distal humerus shaft discovered on her outpatient appointment on 1/29/25 (nine days after admission) and requiring new surgical intervention. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 14. The findings include: R1's face sheet shows she is an [AGE] year old female admitted to the facility on [DATE], with diagnoses included unspecified fracture of shaft of humerus left arm, orthopedic aftercare, cognitive communication deficit, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting left… […]