Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fair Oaks Healthcare Center during CMS and state inspections, most recent first.
A resident with CHF, muscle weakness, asthma, and moderate cognitive impairment was incorrectly deemed to lack decision-making capacity when an ADON entered an order stating she could not understand choices or make health care decisions, relying on hospital documentation that only described her capacity as limited and requiring surrogate input for complex decisions. The physician’s H&P and MDS indicated she could make some choices, and she clearly expressed a desire to go out with a friend and to change her DPOA due to family restrictions, but the facility did not inform Social Services to review or update her DPOA. A MoCA score later showed mild impairment, and facility materials described MoCA as only a screening tool, yet there was no documented comprehensive capacity evaluation before the facility restricted her rights, resulting in a failure to support her self-determination and exercise of rights.
A resident with significant medical needs and cognitive intactness reported to family that a CNA handled her roughly during incontinence care. The family notified staff, but no investigation, interviews, or documentation occurred, and the only action taken was to remove the CNA from working with the resident, contrary to facility grievance policy.
A resident with a history of aggressive behavior and dementia physically assaulted another resident in the dining room when staff failed to provide required supervision, despite care plans and staff awareness of the risk. The assaulted resident, who had major depression and intact memory, reported feeling scared and confirmed previous attacks by the same individual. Staff interviews and records indicated that the aggressive resident had a pattern of altercations and required frequent supervision, which was not consistently provided.
A resident with severe cognitive and physical impairments, identified as high risk for falls, was injured after sliding off the edge of a low bed while being assisted with dressing by a CNA who used a Chux pad, making the surface slippery. The resident sustained a right hip fracture, and staff interviews revealed improper positioning and inadequate supervision during care, as well as inconsistent documentation and pain assessment.
A resident with multiple diagnoses, including diabetes and heart disease, was not provided with STAT blood tests as ordered by a physician to evaluate treatment for a UTI. The facility's records lacked evidence of the tests being completed, and the resident was later hospitalized with acute encephalopathy due to an untreated infection. Interviews revealed that the facility did not follow proper procedures for STAT orders, contributing to the resident's condition worsening.
A resident with multiple health issues, including a UTI, had STAT blood tests ordered to assess treatment response. The facility failed to document the completion, cancellation, or rescheduling of these tests, and did not record the resident's refusal or physician notification. This led to confusion among staff about whether the tests were performed.
The facility failed to maintain accurate medication reconciliation and storage, leading to loose pills in medication drawers and misplaced blister packs. A resident's controlled medication records did not reconcile between the CDR and MAR, posing a risk of medication diversion. The DON and staff acknowledged these discrepancies, which violated the facility's policies on medication management.
The facility failed to properly label and store medications, including an expired lidocaine bottle and an unlabeled glucagon kit, as well as an open bottle of glucose test strips without an open date label. These issues were confirmed by LNs and the DON, violating the facility's medication policies.
The facility was found deficient in food storage and staff hygiene practices. Raw ground beef was stored above vegetables, and dry foods were left unsealed, risking contamination and pest attraction. A Restorative Nursing Assistant entered the kitchen without washing hands or wearing hair restraints, and a Dietary Aide did not cover facial hair, both violating infection control protocols.
The facility failed to maintain effective infection control, with staff removing N95 masks inside isolation rooms, visitors entering COVID rooms without proper PPE, and staff lacking N95 fit tests. Additionally, residents' medical equipment was improperly handled, and a staff member provided care without required PPE.
A facility failed to provide an accurate MDS assessment for a resident, leading to incorrect health status data. The resident, admitted with orthopedic aftercare and pain, was inaccurately recorded as not receiving pain medication, despite records showing administration of Norco and Tylenol. Interviews with the resident and staff confirmed the oversight, with the MDS Coordinator acknowledging the error.
A facility failed to consistently monitor a resident's intake and output for enteral feeding as per physician's orders. The resident, with a nasogastric tube and diagnoses including cerebral infarction and aphasia, had missing records for intake and output monitoring on two shifts. Interviews confirmed the oversight, highlighting the importance of following orders to ensure adequate nutrition and fluid balance.
A resident with a history of cerebral infarction, muscle weakness, Parkinson's disease, and osteoarthritis did not receive appropriate pain management due to the facility's failure to follow physician's orders. Despite the resident's moderate pain levels, Acetaminophen was administered instead of the prescribed Acetaminophen-Codeine. Interviews with staff confirmed the oversight, highlighting a breach in the facility's pain management and medication administration protocols.
A resident's antipsychotic medication was discontinued without notifying their representative, leading to behavioral changes and family frustration. The facility's policy required notification of such changes, which was not followed, as confirmed by staff and the Director of Nursing.
A resident with parkinsonism and ataxia suffered burns on her fingers after attempting to eat hot cereal without adequate supervision. A CNA, unfamiliar with the resident's care needs, microwaved the cereal and left it unattended, leading to the incident. The facility's policy required supervision for residents with such needs, which was not provided in this case.
A resident with parkinsonism and ataxia suffered burns to her fingers after attempting to feed herself without assistance. The facility failed to promptly notify the resident's family, as required by their policy. The family was informed four days later, contrary to the facility's procedures for notifying resident representatives of accidents or incidents resulting in injury.
A resident with parkinsonism and ataxia sustained burns on two fingers after spilling hot cereal. The facility failed to ensure timely and accurate assessments by an RN, resulting in inconsistent evaluations and delayed treatment. LVNs documented the incident but acknowledged their limitations in performing assessments, which are the responsibility of RNs. The facility did not adhere to Nursing Practice guidelines, leading to inadequate assessment and treatment of the resident's injuries.
A resident with parkinsonism and ataxia sustained burns while attempting to self-feed without CNA assistance, leading to a delay in care plan revision. The incident was documented, and new orders were issued, but the care plan was not updated until several days later. The DON confirmed the delay, which contradicted the facility's policy requiring timely updates.
A resident with diabetic foot ulcers did not receive wound care as ordered, with missing documentation for several shifts. The facility's policy required accurate documentation of services, but this was not followed, and no progress notes explained the omissions. The DON confirmed the lack of documentation, and the facility could not provide a policy for following physician orders.
A resident with a history of diabetes and peripheral vascular disease developed a wound on the right foot second toe, which was not properly monitored or documented by the facility. The resident missed multiple podiatry appointments due to a failure in arranging transportation services. These deficiencies led to the worsening of the wound and ultimately resulted in a partial foot amputation.
The facility failed to ensure a qualified Infection Preventionist (IP) was available to meet all requirements for a census of 141 residents. The IP left in January 2024, worked zero hours in February, and did not attend the quarterly QA meeting. The Director of Staff Development (DSD) was not certified to perform IP duties, leaving the facility without a qualified IP, which decreased the potential to prevent infection spread.
A facility failed to maintain effective infection control during a wound treatment for a resident with PVD and diabetes. The nurse did not clean bandage scissors, placed supplies on the bed, and did not perform hand hygiene, increasing the risk of cross-contamination and infection.
Improper Capacity Determination and Failure to Support Resident in Changing DPOA
Penalty
Summary
The facility failed to honor a resident’s right to a dignified existence, self-determination, and exercise of rights by improperly determining that the resident lacked capacity without adequate clinical assessment or legal authority, and by not supporting her in updating her Durable Power of Attorney (DPOA). The resident was admitted with diagnoses including congestive heart failure, muscle weakness, and asthma. Hospital SNF orders documented that her capacity for medical decision making was “limited,” stating she seemed able to make very basic medical decisions and that more complex decisions would require input from a surrogate. Despite this, the Assistant Director of Nursing entered a facility order stating the resident did not have the capacity to understand choices and make health care decisions, based solely on the hospital documentation, which did not support a finding of incapacity. The ADON had no legal authority to determine capacity, and there was no documentation showing the resident lacked capacity. The physician’s History & Physical documented that the resident could make some choices, and the admission MDS showed a BIMS score of 10 (moderate cognitive impairment) with no delirium or behavioral symptoms. The DON could not explain why the order declaring no capacity was created and incorrectly stated that a BIMS score less than 9 would mean a resident did not have capacity. The resident reported wanting to go out to lunch with a friend but said her family would not allow it, became emotional and cried, and stated she wanted to change her DPOA because of her family’s actions. A physician visit note documented that the physician reviewed the resident’s record, found an advance directive listing a granddaughter as DPOA, and intended for the social worker to review the document with the resident to see if she wanted to update it, indicating the physician considered her capable of reviewing and updating her DPOA. The Social Services Director stated she was never informed she needed to review the DPOA with the resident. A subsequent change-in-condition note showed the physician wrote that the resident was “felt to lack capacity” and requested a MoCA to confirm; the MoCA score was 15/30, and the DON stated a score below 10 would indicate lack of capacity, but there was no documentation that the physician further evaluated the resident after the MoCA. Facility educational material stated the MoCA was a screening tool and might not accurately diagnose cognitive impairment. Later physician documentation, provided after the survey, stated that the MoCA score was consistent with mild dementia and that the resident did not have capacity for medical decision making, along with a new diagnosis of major neurocognitive disorder, but the report shows that during the survey period the facility had already treated the resident as lacking capacity without adequate assessment or proper support for her expressed wish to change her DPOA, contrary to the facility’s Resident Rights policy.
Failure to Investigate and Document Resident Grievance of Rough Handling
Penalty
Summary
The facility failed to properly investigate a complaint of mistreatment involving a resident who was cognitively intact and required maximal assistance for toileting hygiene due to multiple medical conditions, including malignant neoplasm of the cauda equina, COPD, neuromuscular bladder dysfunction, and anxiety disorder. The resident's family member reported to facility staff that the resident had been handled roughly by a CNA during incontinence care. Despite this report, there was no documentation in the resident's chart regarding the complaint, the reporting of the incident, or any follow-up actions taken by staff. Interviews with facility staff, including licensed nurses, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), RN Case Manager (CM), and Director of Staff Development (DSD), revealed that none of them conducted interviews with the resident or the CNA involved regarding the alleged rough handling. The SSD and CM acknowledged that they did not document the complaint or any follow-up actions. The DSD confirmed that no one spoke to the CNA about the incident, and no disciplinary counseling, education, or in-service was conducted in response to the complaint. The facility's policy required that all grievances or complaints be investigated, documented, and responded to both verbally and in writing, with a written summary provided to the resident or their representative. However, the facility did not follow these procedures, as there was no investigation, documentation, or communication of findings to the resident or family. The only action taken was to remove the CNA from working with the resident, without any formal investigation or staff education.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to provide a safe and protective environment free from physical abuse for one of three sampled residents when a resident with a history of aggressive behavior and dementia physically assaulted another resident in the dining room. The resident who was assaulted had a diagnosis of major depression and intact memory, while the aggressor had moderately impaired cognition and a documented history of physical altercations, poor impulse control, and anger. The care plan for the aggressive resident specified the need for staff supervision in the dining room, but this supervision was not provided at the time of the incident. Multiple staff interviews confirmed that the aggressive resident had been involved in previous altercations and required frequent supervision, which was not consistently implemented. The incident occurred when the assaulted resident attempted to move a chair to sit with a friend, prompting the aggressive resident to hit her in the arm and back of the head. The assaulted resident reported feeling scared and stated this was not the first time she had been attacked by the same individual. Observations and interviews with staff and other residents confirmed ongoing aggressive behavior by the resident with dementia, and that the lack of supervision allowed for repeated incidents of physical abuse. The facility's policy states that residents have the right to be free from all forms of abuse, but this was not upheld in this case.
Failure to Prevent Resident Injury During Bedside Care
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including severe cognitive impairment, hemiplegia, hemiparesis, osteoporosis, and a high risk for falls, was not adequately protected from accident hazards during care. The resident required maximal assistance for activities of daily living and was dependent for bed mobility. While being assisted with dressing by a CNA, the resident was positioned at the edge of a low bed with a Chux pad underneath, which contributed to the resident sliding off the bed and onto the floor. The CNA acknowledged that sitting the resident at the edge of the bed with a Chux pad was a mistake, as it made the surface slippery and difficult to control the resident's movement. Following the incident, the resident initially did not complain of pain, but later developed significant right hip pain. Assessment and interviews revealed that the resident had sustained a minimally displaced right intertrochanteric hip fracture as a result of the fall. The resident's care plan had identified a high risk for falls and set a goal to prevent falls, but the interventions in place were not sufficient to prevent this incident. Staff interviews indicated that the bed was kept in a low position during care, which made it difficult for the CNA to maintain balance and safely assist the resident, and that the use of a Chux pad further increased the risk of sliding. Documentation and communication following the fall were inconsistent, with pain medication administered "in case" of pain and pain levels documented that did not match the resident's reported symptoms at the time. The facility's policies and procedures on fall risk and prevention emphasized the need for individualized interventions and proper assessment of risk factors, but these were not effectively implemented in this case. The failure to provide adequate supervision and to ensure a safe environment directly resulted in the resident's injury, decreased mobility, and increased pain.
Failure to Perform STAT Blood Tests Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide nursing services in accordance with professional standards of practice for a resident when it did not follow a physician's order to perform laboratory blood tests. The resident, who was admitted in 2023 with multiple diagnoses including diabetes mellitus, lung, and heart diseases, was diagnosed with dehydration and a urinary tract infection (UTI). The physician ordered two blood tests to be completed immediately (STAT) to evaluate the resident's response to treatment for the UTI. Despite the physician's order, there was no documented evidence that the blood tests were carried out on the specified date or at any later time. The facility's Patient Service Log did not show if the tests were completed, canceled, or rescheduled. Interviews with nursing staff revealed that the STAT order required immediate action, including entering the order into the computer and notifying the laboratory. However, the Director of Nursing confirmed that the tests were not performed and that there was no documentation of the physician being notified of the resident's refusal to undergo the tests. The resident experienced a change in condition and was sent to the emergency department, where they were diagnosed with acute encephalopathy secondary to an acute urinary infection. The resident was hospitalized for nine days and received treatment with multiple antibiotics. The facility's failure to carry out the physician's order for STAT blood tests potentially contributed to the resident's continued infection and subsequent hospitalization.
Failure to Document Blood Test Orders and Physician Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to confusion among staff regarding the completion of ordered blood tests. The resident, who was admitted with multiple diagnoses including diabetes mellitus, lung, and heart diseases, was diagnosed with a urinary tract infection. A physician ordered two STAT blood tests to assess the resident's response to treatment for the infection. However, there was no documentation in the resident's medical records indicating that the tests were performed, canceled, or rescheduled, nor was there evidence that the physician was notified of the resident's refusal to undergo the tests. Interviews with facility staff revealed that the nurse failed to document the resident's refusal and the subsequent notification to the physician, as well as the rescheduling of the tests. The Director of Nursing confirmed the absence of documentation and acknowledged that the tests were not carried out as ordered. The facility's policies on telephone orders and charting and documentation require that all services, changes in condition, and communications with physicians be accurately recorded in the resident's medical records, which was not adhered to in this case.
Medication Reconciliation and Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper pharmacy services, resulting in discrepancies in medication reconciliation and storage. During observations, loose medications were found in the medication drawers of carts in different wings, which were verified by licensed nurses. These loose pills were not supposed to be there, and the staff acknowledged the need for proper disposal. The Director of Nursing (DON) demonstrated the medication retrieval and destruction process, emphasizing that loose pills should be removed to prevent medication errors. The facility's policy on medication labeling and storage requires medications to be stored in an orderly manner to prevent mixing. Additionally, a medication blister pack with a resident label was found misplaced at the back of a medication drawer. The DON confirmed that the medication should not have been stored in this manner, as it led to the staff being unable to locate it, necessitating an early reorder against the pharmacist's advice. This incident highlights the facility's failure to adhere to its policy of orderly medication storage, which is crucial for ensuring that each resident's medications are correctly managed and accessible. Furthermore, the facility did not reconcile controlled medication records for a resident, as evidenced by discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). The resident, who had an intact cognitive status, was receiving pain medication, but the administration was not documented on the MAR on two occasions, despite being signed out from the CDR. The DON and a nurse consultant confirmed that both records should match to ensure accountability for controlled medications, as per the facility's policies. This failure posed a risk of medication diversion and highlighted the need for accurate documentation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which was observed during a survey. An expired medication was found stored in a treatment cart alongside active medications, specifically a multi-dose bottle of liquid lidocaine with an expiration date of January 2024. This was confirmed by a Licensed Nurse (LN) who acknowledged that the medication should have been discarded according to the facility's policy. Additionally, an emergency glucagon kit was found without a resident-specific pharmacy label, which was also confirmed by the LN and the Director of Nursing (DON) as a violation of the facility's medication labeling policy. Furthermore, an open bottle of glucose test strips was found without an open date label, which is necessary to ensure the strips are used within the manufacturer's recommended timeframe. This was verified by another LN, who confirmed the absence of the open date label. The DON also stated that the open date label is required to prevent the use of expired strips. These deficiencies in medication management increased the risk of administering expired or incorrectly labeled medications, potentially compromising resident safety.
Deficiencies in Food Storage and Staff Hygiene Practices
Penalty
Summary
The facility failed to adhere to safe food storage and handling practices, as observed during a survey. Raw ground beef was improperly stored above vegetables in the kitchen's walk-in freezer, which the Dietary Manager acknowledged could lead to contamination from meat drips. Additionally, in the dry pantry, uncooked lasagna pasta, polenta powder, and chocolate chips were found unsealed, which the Dietary Manager confirmed should have been stored in food-grade plastic bags to prevent pest attraction. Furthermore, there were lapses in personal hygiene and safety protocols among staff. A Restorative Nursing Assistant entered the kitchen without washing hands or wearing hair and facial hair restraints, which he admitted was against infection control practices. The Dietary Manager stated that only kitchen staff should enter the kitchen, and the RNA should have waited outside for his meal tray. Additionally, a Dietary Aide was observed with a long mustache and beard not covered by a facial hair restraint, which he acknowledged was required while working in the kitchen.
Infection Control Deficiencies in PPE Use and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. Two staff members were seen removing their N95 masks inside a droplet isolation precaution room before exiting, contrary to the facility's guidelines and CDC recommendations. The Infection Preventionist and Director of Nursing confirmed that the practice should be to remove the N95 mask after leaving the room and closing the door. Additionally, two visitors entered a COVID isolation room without the required PPE, wearing only surgical masks, despite the facility's policy requiring adherence to transmission-based precautions by visitors. Further deficiencies were noted in the fit testing of N95 masks for staff. Four out of five sampled staff members, including a Licensed Nurse, Certified Occupational Therapist Assistant, Unit Secretary, and Certified Nurse Assistant, had not undergone the required N95 fit testing upon hire, as confirmed by the Infection Preventionist and Director of Nursing. This lack of fit testing contravenes OSHA requirements and compromises the expected level of protection for staff working in environments with potential exposure to airborne pathogens. Additional infection control issues were observed with residents' medical equipment. Resident 395's nasal cannula was found on the floor and uncovered, which the Infection Preventionist and Director of Nursing acknowledged as a contamination risk. Similarly, Resident 120's urinary drainage bag was observed on the floor on two occasions, posing a risk of infection due to potential backflow. Lastly, a staff member provided care to Resident 42, who was on Enhanced Barrier Precautions, without wearing the required gown and gloves, as confirmed by the facility's policy and the Nurse Consultant.
Inaccurate MDS Assessment for Pain Management
Penalty
Summary
The facility failed to provide an accurate Minimum Data Set (MDS) assessment for one resident, identified as Resident 131, which led to inaccurate health status data. Resident 131 was admitted in September 2024 with diagnoses including orthopedic aftercare, pain in the right lower leg, and diabetes mellitus. The MDS assessment, dated 9/9/24, inaccurately indicated that Resident 131 did not receive scheduled and PRN pain medication in the last five days, despite records showing that the resident had been receiving pain medication, including Norco and Tylenol, since admission. Interviews with Resident 131 and facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the inaccuracy in the MDS pain management assessment. The MDS Coordinator acknowledged the oversight, stating that the pain management questions might have been missed. The Director of Nursing also expressed the expectation for MDS assessments to be accurate to ensure the facility has an accurate resident health status. The facility's policy requires staff to certify the accuracy of the MDS assessments, which was not adhered to in this case.
Failure to Monitor Enteral Feeding Intake and Output
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with enteral feeding, specifically regarding the monitoring of intake and output as per the physician's orders. Resident 396, who was admitted with diagnoses including cerebral infarction, muscle weakness, and aphasia, was observed to have a nasogastric tube for feeding. The physician's order required intake and output monitoring every shift, but this was not consistently followed, as evidenced by missing records on the night shift of October 10 and the day shift of October 13. Interviews with the licensed nurse and the Director of Nursing confirmed the oversight in monitoring, emphasizing the importance of adhering to the physician's orders to ensure adequate fluid balance and nutrition for the resident. The facility's policy on enteral nutrition also highlighted the need for monitoring to detect signs of inadequate nutrition and altered hydration. This lapse in monitoring increased the potential for inadequate care and compromised the resident's well-being.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to provide appropriate pain management services for a resident, identified as Resident 69, by not adhering to the physician's orders for pain medication. Resident 69, who was admitted in August 2024, had a history of cerebral infarction, muscle weakness, Parkinson's disease, and osteoarthritis, conditions that can cause significant pain. The resident's cognitive assessment indicated intact cognition, and she reported experiencing pain for which she took medication. The physician's orders specified the administration of Acetaminophen for mild pain and Acetaminophen-Codeine for moderate to severe pain. However, the Medication Administration Record (MAR) showed that Acetaminophen was administered on several occasions when the resident's pain level was recorded as moderate, according to the facility's pain scale protocol. Interviews with facility staff, including a Licensed Nurse (LN) and the Director of Nursing (DON), confirmed that the physician's orders were not followed on specific dates when the resident's pain was assessed as moderate. The facility's policy and procedure for pain management and medication administration require adherence to prescriber orders and assessment of pain intensity using a numeric scale. The failure to follow these protocols resulted in the potential for the resident not to achieve relief from pain and not attain her highest practicable well-being.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative when an antipsychotic medication, Seroquel, was discontinued for a long-term resident with diagnoses including memory problems with agitation, anxiety disorder, and legal blindness. The resident's medical record indicated that Seroquel was discontinued without notifying the resident's representative or family members, leading to a change in the resident's behavior, including screaming and refusing to listen to family members during visits. The family was not informed of the medication change until it was reinstated, causing frustration and confusion about the resident's altered behavior. Interviews with the resident's family and facility staff confirmed that the facility did not follow its policy of notifying the resident's representative of changes in the resident's care, including medication changes. The Director of Nursing acknowledged that the resident's representative should have been informed when Seroquel was discontinued. The lack of notification resulted in the family being unaware of the medication change and its impact on the resident's behavior, which was only resolved when the medication was reinstated.
Resident Burned Due to Inadequate Supervision During Meal
Penalty
Summary
The facility failed to ensure the safety of a resident during breakfast, resulting in burns and blisters on two of the resident's fingers. The resident, who was admitted with diagnoses including parkinsonism and ataxia, required assistance with eating due to tremors. On the day of the incident, a CNA, who was not familiar with the resident's care, microwaved the resident's hot cereal and left it unattended on the tray. The resident attempted to check the temperature of the cereal, resulting in the hot cereal spilling on her hand and causing burns. The CNA admitted to not testing the temperature of the cereal before serving it and acknowledged that it was likely too hot. Despite the presence of a thermometer and instructions to ensure liquids do not exceed 145 degrees, the CNA did not use the thermometer. The Director of Nursing confirmed that the resident required supervision during meals due to her inability to feed herself. The facility's policy on safety and supervision emphasized the need for resident supervision based on individual needs and environmental hazards.
Failure to Notify Family of Resident's Injury
Penalty
Summary
The facility failed to promptly notify the responsible party or family member of a resident when the resident experienced burns to two fingers. The resident, who was admitted in May 2020 with diagnoses including parkinsonism and ataxia, attempted to feed herself without CNA assistance and spilled hot cereal, resulting in burns to her left hand. A nurse's progress note documented the incident, but there was no evidence that the resident's responsible party or family member was notified at the time of the injury. The deficiency was further highlighted during a review of the resident's change of condition evaluation, which showed that the family member was only notified four days after the incident. Interviews with the Director of Nursing and a licensed nurse confirmed that the facility's policy required prompt notification of the resident's representative in such cases, but this was not adhered to. The facility's policy, revised in February 2021, clearly stated the requirement for prompt notification in the event of an accident or incident resulting in injury.
Failure to Ensure Timely and Accurate Resident Assessment
Penalty
Summary
The facility failed to ensure accurate and timely assessments of a resident's injuries, leading to inconsistent evaluations and a delay in appropriate treatment. The resident, who was admitted with diagnoses including parkinsonism and ataxia, sustained burns on two fingers of the left hand after spilling hot cereal due to tremors. Despite the incident being documented by various Licensed Vocational Nurses (LVNs) over several days, there was no documented assessment by a Registered Nurse (RN), Nurse Practitioner (NP), or Physician on the day of the injury. This lack of assessment resulted in the absence of a diagnosis regarding the severity of the burns. Interviews with staff revealed that LVNs acknowledged their limitations in performing physical assessments and diagnosing injuries, which are responsibilities designated to RNs. The Director of Nursing confirmed that RNs are expected to conduct assessments. The report highlights that the facility did not adhere to the Nursing Practice guidelines, which stipulate that only RNs can perform comprehensive assessments, analyze data, and formulate nursing diagnoses. This oversight led to the resident's injuries being inadequately assessed and treated.
Delayed Care Plan Revision After Resident Injury
Penalty
Summary
The facility failed to revise a resident's care plan in a timely manner after the resident sustained an injury. The resident, who was admitted in May 2020 with diagnoses including parkinsonism and ataxia, attempted to feed themselves without CNA assistance, resulting in hot cereal spilling and causing burns to two fingers on their left hand. A nurse progress note documented the incident, and a Nurse Practitioner wrote new orders to monitor the burn site. Despite the incident occurring on April 22, 2024, the care plan was not updated until April 26, 2024. During an interview and record review on June 5, 2024, the Director of Nursing confirmed that the care plan had not been revised promptly, stating that care plans should be updated the day of or the next day at the latest. The facility's policy, revised in March 2022, emphasizes that care plans should be revised as residents' conditions change, highlighting the deficiency in this case.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care treatment were followed for a resident with open wounds on both lower legs, diabetes mellitus, and atherosclerosis. The resident was admitted with specific orders for monitoring and treating diabetic foot ulcers on both legs. However, the Treatment Administration Record (TAR) for April 2024 showed that monitoring was not documented for 20 out of 70 shifts, and wound care treatment was not documented for several shifts on both legs. The absence of documentation and progress notes indicated that the treatments were either not performed or not recorded, as confirmed by the Licensed Nurse and the Director of Nursing. The facility's policy required all services provided to residents to be documented accurately in their medical records, but this was not adhered to in the case of the resident. The Director of Nursing confirmed the lack of documentation and progress notes explaining why the treatments were not completed. Additionally, the facility could not provide a policy and procedure regarding the standard for following physician orders, which is a legal duty for licensed nurses according to the California Nursing Act.
Failure to Provide Proper Foot Care Leads to Amputation
Penalty
Summary
The facility failed to ensure proper foot care for a resident, leading to a partial right foot amputation. The resident, who had a history of peripheral vascular disease, diabetes, heart failure, peripheral neuropathy, and a previous partial left foot amputation, developed a wound on the right foot second toe. There was a lack of documentation indicating that the wound was being assessed per nursing standards, and the resident missed multiple podiatry appointments due to a failure in arranging transportation services. These missed appointments and inadequate wound monitoring contributed to the worsening of the resident's condition, ultimately resulting in the need for surgical intervention. The resident's care plan included monitoring for signs of skin breakdown and ensuring podiatry consultations as ordered. However, the facility's records showed no documented evidence of consistent wound assessments or discussions in weekly wound meetings. The wound on the resident's right second toe persisted from December 2023 to February 2024 without proper documentation of its progress or any significant intervention. The treatment nurse admitted to not closely monitoring the wound, and the Director of Nursing confirmed that the lack of documentation made it impossible to determine if the wound was improving. Interviews with staff revealed a breakdown in communication and responsibility regarding the resident's care. The Social Services Coordinator was responsible for arranging transportation to outside appointments but failed to do so, leading to missed podiatry visits. The nursing staff did not adequately document or monitor the resident's wound, and the physician was not notified of the wound's lack of healing in a timely manner. This series of failures in communication, documentation, and care ultimately led to the resident's partial foot amputation.
Failure to Maintain Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure an Infection Preventionist (IP) was available to meet all the requirements of the position for a census of 141 residents. The Executive Director (ADM) stated that the full-time IP left in January 2024 and worked part-time during February 2024. However, time sheets indicated the IP worked zero hours from 2/1/24 to 2/15/24, and no time sheets were provided for the latter half of February. The ADM confirmed that no further time sheets were sent to the Department, and the IP did not attend the facility's quarterly Quality Assurance (QA) meeting on 1/25/24. The Director of Nursing (DON) acknowledged the importance of having an IP present in the building and at QA meetings. The Resource Nurse Consultant (RNC) initially indicated that the Director of Staff Development (DSD) was performing IP duties, but later confirmed that the DSD was not certified to perform the role of an IP and was not acting as the facility's IP. The facility's policy and procedure for the Infection Prevention and Control Program, revised in October 2018, stated that the program should be coordinated and overseen by an infection prevention specialist. The ADM and other staff interviews confirmed that the facility did not have a qualified IP in place during the period in question, which decreased the facility's potential to prevent the spread of infection among staff and residents. The ADM acknowledged the absence of an IP and the failure to provide necessary documentation to the Department, highlighting a significant gap in the facility's infection control measures.
Infection Control Deficiency During Wound Treatment
Penalty
Summary
The facility failed to maintain an effective infection prevention program for one resident when the Treatment Nurse did not follow proper infection control practices during a wound treatment. The nurse did not clean bandage scissors before or after cutting a soiled wound dressing, placed treatment supplies directly on the resident's bed, and did not perform hand hygiene during the procedure. These actions were observed during a bandage change for a resident with peripheral vascular disease and diabetes, conditions that slow the body's ability to heal wounds. During the bandage change, the nurse placed a plastic bin of treatment supplies and a box of disposable gloves directly on the resident's bed and put on gloves without performing hand hygiene. The nurse used uncleaned bandage scissors to cut off the old bandages, placed the scissors on the bed, and removed the soiled bandages without changing gloves or performing hand hygiene. The nurse then picked up a cup with bandages soaking in a reddish-brown liquid and planned to apply povidone-iodine to the wound without changing gloves. The procedure was stopped for safety concerns, and the nurse acknowledged not changing gloves or performing hand hygiene. Upon resuming the bandage change, the nurse put on new gloves without performing hand hygiene, applied povidone-iodine, and continued to wrap the wound. After completing the procedure, the nurse did not clean the bandage scissors before putting them back in the pouch and returned the supplies to the treatment cart. The Assistant Director of Nursing and the Director of Staff Development both stated that the nurse's actions did not follow the facility's infection control practices, which require hand hygiene, clean surfaces for supplies, and cleaning of reusable equipment to prevent cross-contamination and infection.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 469 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fair Oaks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citrus Heights Post Acute | 1.3 mi | — | 1 | 0 |
| Manzanita Healthcare Center | 3.8 mi | — | 15 | 0 |
| Sacramento Post-acute | 4.3 mi | — | 16 | 0 |
| American River Center | 4.6 mi | — | 12 | 0 |
| Casa Coloma Health Care Center | 4.6 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Fair Oaks Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.