Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health Care Center during CMS and state inspections, most recent first.
A resident sustained a subdural hematoma and scalp hematoma after falling from a mechanical lift sling when CNAs improperly attached the sling loops to the lift bar during a transfer to a wheelchair. Staff wrapped the sling straps around the end/outer hook of the lift bar, creating tension that caused the loop to come off the hook while the resident was being moved. This occurred despite an existing Safe Resident Handling/Transfers Policy that required staff to follow safe handling and transfer practices.
A resident with multiple medical conditions and identified as high fall risk was transported in a wheelchair without footrests by a CNA, resulting in the resident's feet contacting the floor and a subsequent fall that caused a broken nose and a forehead laceration requiring sutures. Staff interviews confirmed that footrests were not routinely used, and there was no documentation of refusal by the resident. The facility lacked a specific wheelchair transport policy addressing footrest use, contributing to the incident.
A facility failed to notify a physician about a resident's rash on the day it was identified, as required by their protocol. A PTA noticed the rash and believed she reported it to a nurse, but the RN on duty was not informed. The NP was only notified four days later, just before the resident's discharge. The facility lacked documentation of the notification, violating their policy for handling acute condition changes.
A facility failed to assess a resident's rash after it was observed by a Physical Therapy Assistant. The PTA reported the rash to a nurse, but the nurse did not recall being informed. The Infection Control Preventionist stated that rashes should be reported to her and assessed by a physician. The facility lacked documentation of a skin assessment for the resident, contrary to their policy requiring staff to communicate changes in skin conditions.
The facility failed to serve the correct portion of vegetables during meal service, using a 2.66-ounce scoop instead of the required 4-ounce portion. This affected several residents, resulting in a more than 30% deficit in the vegetable serving size. The Dietary Manager confirmed the error, which occurred despite the dietitian's review of the menu.
A staff member in an LTC facility failed to sanitize a thermometer before measuring the temperature of sloppy joe meat, leading to potential cross-contamination. The thermometer was stored with writing utensils and used without cleaning, as confirmed by the Dietary Manager. This affected several residents dining in the adjacent dining room.
A resident with dysphagia and dementia was observed choking during lunch, but the Heimlich maneuver was not immediately performed. Instead, an RN sought assistance from the DON before attempting the maneuver, which was ineffective. CPR was initiated, and EMS was called, but lifesaving measures were unsuccessful, and the resident was pronounced dead. The facility's emergency procedure for choking was not followed.
A resident with multiple pressure ulcers did not receive timely pressure-relieving interventions, such as a special mattress, upon admission. The facility lacked a care plan addressing the resident's wounds, despite the resident's high risk for further skin breakdown due to complex medical conditions. The wound care nurse and DON acknowledged the oversight, and the care plan/MDS coordinator admitted the care plan interventions were not properly implemented.
A resident with a history of falls and multiple diagnoses, including vascular dementia and mobility issues, did not have a care plan identifying fall risk or interventions. After a fall resulting in injuries, the facility failed to reassess the resident's fall risk or update the care plan, contrary to policy. The DON and MDS Coordinator confirmed the lack of a fall risk care plan, despite the resident being identified as high risk upon admission.
A facility failed to have physician orders for a resident with an indwelling urinary catheter. The resident, with a history of prostate cancer and a recent staph infection, was admitted with the catheter but lacked documented care orders or interventions. The DON confirmed that such orders are necessary to ensure resident safety and prevent infections, as outlined in the facility's policies.
A facility failed to accurately reconcile controlled substances for a resident prescribed hydrocodone/acetaminophen. Documentation errors were noted, with discrepancies in the Controlled Drug Receipt/Record/Disposition form, including stricken entries and missing signatures. A staff member acknowledged the inability to determine the disposition of a missing tablet and stated that discrepancies should be reported immediately. The facility's policy requires controlled substances to be counted at each shift change and any waste to be documented with two signatures.
The facility failed to prevent cross-contamination and ensure proper PPE use. A CNA did not change gloves or perform hand hygiene after assisting a resident with toileting, while two staff members did not wear gowns during a transfer of a resident on enhanced barrier precautions. These actions violated the facility's infection control policies.
Improper Mechanical Lift Sling Attachment Leads to Resident Fall and Head Injury
Penalty
Summary
The facility failed to ensure a resident was transferred with a mechanical lift in a safe manner, resulting in the resident falling from the lift sling and sustaining a subdural hematoma. The resident was an elderly female who had been admitted to the facility and was later readmitted with a new diagnosis of traumatic subdural hematoma. According to the State Agency Serious Injury Report, the resident was hospitalized after falling from a mechanical lift sling due to improper sling attachment to the lift hooks. A hospital discharge report documented that the resident was admitted with a subdural hematoma and a scalp hematoma, with a CT scan showing a 3-millimeter subdural hematoma. Interviews with the Administrator and the CNAs involved in the transfer revealed that the improper use of the sling loops led to the incident. The Administrator stated that, after interviewing the CNAs, they were able to determine and recreate how the sling loop came off the lift hook: the loop strap had been wrapped around the end of the transfer bracket, creating tension that caused the loop to pop off the hook. One CNA reported that during the transfer to a wheelchair, the other CNA hooked their side of the sling and then wrapped the rest of the strap around the end of the lift bar, after which the sling came off and the resident fell. The other CNA similarly stated that they hooked the loop of the sling on the lift bar and wrapped the rest around the outer hook of the bar, and when the resident was lifted and moved toward the wheelchair, the sling came undone and the resident fell to the floor. At the time of the injury, the facility’s Safe Resident Handling/Transfers Policy required staff to maintain compliance with safe handling and transfer practices.
Failure to Ensure Safe Wheelchair Transport for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure safe wheelchair transport for a resident identified as high fall risk. The resident, who had multiple diagnoses including dementia, neuromuscular dysfunction, muscle wasting, abnormalities of gait and mobility, and was cognitively intact, was transported in a wheelchair without footrests in place. During transport, the resident's shoes made contact with the floor multiple times, and it was observed that footrests were not used despite the resident not refusing them. The resident reported that footrests had not been used for some time and acknowledged that they help prevent his feet from hitting the floor. The incident leading to the deficiency involved a CNA propelling the resident in his wheelchair when the resident fell forward, resulting in a broken nose and a laceration to the forehead that required sutures. Staff interviews revealed that it was common practice to transport the resident without footrests, relying on the resident to lift his feet. There was no documentation indicating that the resident refused the use of footrests, and staff were unable to confirm if the available footrests belonged to the resident's wheelchair. The facility's Director of Nursing and therapy staff confirmed that footrests are an important safety measure during wheelchair transport to prevent accidents. The facility did not provide a specific wheelchair transport policy when requested. The only available policy referenced safe lifting and movement of residents but did not address the use of footrests during wheelchair transport. The lack of adherence to safe transport procedures and absence of documentation regarding the use or refusal of footrests directly contributed to the resident's fall and subsequent injuries.
Failure to Notify Physician of Resident's Rash
Penalty
Summary
The facility failed to notify the physician of a resident's rash on the day it was identified, which was a deficiency in their protocol for handling acute condition changes. On February 21, 2025, a Physical Therapy Assistant (PTA) noticed a blotchy red rash on a resident's neck and believed she reported it to a nurse, although she was unsure to whom. A Registered Nurse (RN) on duty that day stated she was not informed of the rash, and a Nurse Practitioner (NP) confirmed she was not notified until February 25, 2025, just before the resident's discharge. The facility's administrator acknowledged the lack of documentation regarding the notification of the physician about the rash on the day it was identified. The facility's policy requires direct care staff to recognize and communicate significant changes in a resident's condition to nursing staff, who are then responsible for contacting the physician based on the urgency of the situation.
Failure to Assess Resident's Rash
Penalty
Summary
The facility failed to assess a resident after a rash was observed by staff. On 2/21/2025, a Physical Therapy Assistant noticed a blotchy red area on a resident's neck and believed she reported it to a nurse, although she was unsure to whom. A Registered Nurse stated that no one mentioned the rash to her that day, but she would have assessed the resident and contacted the doctor if informed. The Infection Control Preventionist indicated that a rash should be reported to her by the nurse, and the physician should be involved for assessment and treatment. The facility's Administrator confirmed there was no documentation of a skin assessment for the resident on the day the rash was identified. The facility's policy requires direct care staff to recognize and communicate changes in residents' skin conditions to the nurse.
Inadequate Vegetable Portion Served to Residents
Penalty
Summary
The facility failed to provide the correct portion of vegetables to residents during meal service. On June 4, 2024, during the noon lunch service, a staff member used a green-handled ice cream scoop to serve peas, resulting in an inadequate portion size. The green scoop was identified as 2.66 ounces, whereas the facility's menu and recipe specified a 4-ounce portion. This discrepancy affected five residents reviewed for menus and three additional residents outside the sample. The Dietary Manager confirmed that residents received only 2 and 2/3 ounces of peas, which was more than a 30 percent deficit from the required portion size. The dietitian had reviewed the menu to ensure proper nutrition, but the incorrect scoop usage led to the deficiency.
Improper Food Temperature Measurement Leading to Cross-Contamination
Penalty
Summary
The facility failed to measure food temperature on the steam table in a manner that prevents cross-contamination. During a lunch service, a staff member, identified as V4, was observed using a thermometer to check the temperature of sloppy joe meat without sanitizing the thermometer beforehand. The thermometer was stored in a cup with various writing utensils, and V4 inserted it directly into the food without cleaning it. This action was confirmed by the Dietary Manager, V3, who acknowledged that the thermometer should have been cleaned to prevent cross-contamination. This deficiency affected five residents reviewed for menus in the sample and three residents outside the sample, all of whom dined in the dining room adjacent to the kitchen.
Failure to Initiate Immediate Choking Intervention
Penalty
Summary
The facility failed to immediately initiate potential lifesaving interventions for a resident with dysphagia, dementia, and communication deficit, who was observed to be choking during lunch. The resident was found non-responsive and making gurgling noises, with cyanosis visible on his fingers and lips. Despite the presence of trained staff, the Heimlich maneuver was not immediately performed. Instead, a registered nurse (RN) went to get the Director of Nursing (DON) before attempting the Heimlich maneuver, which was ultimately ineffective. CPR was initiated, and emergency medical services were called, but lifesaving measures were unsuccessful, and the resident was pronounced dead. Interviews with staff revealed that the RN did not start the Heimlich maneuver immediately, believing it would be better to have an extra nurse present in case CPR was needed. The DON confirmed that the Heimlich should have been started immediately upon the onset of symptoms. The facility's emergency procedure for choking indicates that trained staff should assist a choking resident immediately, but this protocol was not followed. The resident's death certificate listed Alzheimer's as the cause of death.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure that pressure relieving interventions were in place for a resident with multiple pressure ulcers. The resident, identified as R18, had a complex medical history including gangrene, MRSA infection, acute myeloblastic leukemia, diabetes mellitus with foot ulcer, and a right leg below knee amputation. Upon admission, R18 had an unstageable pressure ulcer on the coccyx, a stage two pressure ulcer on the right buttock, and an unstageable ulcer on the left posterior ankle. Despite these conditions, the facility did not provide a pressure-reducing mattress until after the resident had been in the facility for some time, and there was no care plan in place addressing the resident's pressure ulcers. The wound care nurse, V9, and the Director of Nurses, V2, acknowledged the absence of a pressure-reducing mattress and a care plan for R18's wounds. V9 noted that the resident was at high risk for further skin breakdown due to her medical condition and lack of proper interventions. The care plan/MDS coordinator, V10, admitted that the care plan interventions were not implemented as they should have been, and the oversight was not caught during the MDS completion. The facility's policy on pressure ulcers emphasized the importance of modifying care plans when wounds do not heal as expected, yet R18's care plan lacked any focus on her wounds or pressure-reducing interventions.
Failure to Implement Fall Risk Interventions
Penalty
Summary
The facility failed to implement necessary interventions for a resident with a history of falls, did not reassess the resident's fall risk after a fall with injuries, and did not develop a care plan identifying the resident as a fall risk. The resident, identified as R11, was admitted with multiple diagnoses including vascular dementia, cognitive communication deficit, and abnormalities of gait and mobility. Despite these conditions, the care plan did not reflect the resident's fall risk or include interventions to prevent falls. On one occasion, R11 was found on the floor in his room with the chair alarm sounding, having sustained multiple skin tears on his left arm. The incident report indicated that the resident had not received bathroom or incontinent care for nearly four hours prior to the fall, despite being on diuretics. Observations and interviews revealed that the care plan information sheet on the resident's bathroom door did not identify him as a fall risk, and no interventions were noted under the safety section. The Director of Nursing and the MDS/Care Plan Coordinator acknowledged the absence of a fall risk care plan and interventions for R11. The facility's policy required a fall risk assessment and care plan upon admission and after any fall, but this was not followed. The resident's electronic medical record lacked documentation of a fall risk care plan, despite the resident being identified as a high fall risk upon admission.
Lack of Physician Orders for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had physician care orders in place. This deficiency was identified for one of the five residents reviewed for catheters in a sample of twelve. The resident, identified as R25, had a history of prostate cancer, a recent staph infection in the shoulder, and was admitted to the facility with an indwelling urinary catheter. However, upon review, there were no physician orders or care plan interventions documented for the use of the catheter in R25's electronic medical record. The Director of Nurses (V2) confirmed that physician orders should be in place for all residents with indwelling catheters at the time of admission, including details such as catheter size, change schedule, and any necessary flushing instructions. V2 acknowledged that R25 was at an increased risk of infection due to his medical history and recent shoulder infection. The facility's policies on Urinary Catheter Care and Care Plans emphasize the importance of having a baseline care plan with physician orders within 48 hours of admission, which was not adhered to in this case.
Controlled Substance Reconciliation Failure
Penalty
Summary
The facility failed to maintain an accurate reconciliation of controlled substances for a resident who was prescribed hydrocodone/acetaminophen, a combination narcotic opioid pain medication. The Controlled Drug Receipt/Record/Disposition form indicated that the medication was to be administered every six hours as needed for pain. However, discrepancies were noted in the documentation. On one occasion, the form showed that one tablet was dispensed, leaving 18 tablets remaining, but subsequent entries were lined out and marked as errors, signed by only one nurse. The form did not account for the dispensing of the 18th tablet, and the two stricken entries did not indicate whether the medication was wasted or destroyed. During an interview, a staff member (V2) acknowledged the inability to determine the disposition of the 18th tablet and stated that if the medication was wasted, it should have been documented and signed by two nurses. V2 also mentioned that controlled substances are counted at the start and end of each shift, and any discrepancies should be reported immediately to the Director of Nursing. The facility's policy requires that any wasted controlled substances be disposed of in the presence of a witness and signed by both nurses. The failure to accurately document and reconcile the controlled substance count was not identified at shift change, and the missing narcotic was not reported to the appropriate personnel.
Infection Control Deficiencies in PPE Use and Cross-Contamination Prevention
Penalty
Summary
The facility failed to prevent cross-contamination during the assistance of a resident, identified as R83, with toileting needs. A Certified Nursing Assistant (CNA), V15, was observed assisting R83, who has multiple diagnoses including a displaced fracture and osteoarthritis, and requires substantial assistance with toileting. V15 used the same gloves to clean R83 after a bowel movement and then proceeded to adjust the resident's clothing and wheelchair without changing gloves or performing hand hygiene, contrary to the facility's policies on glove use and hand hygiene. In another incident, the facility failed to ensure proper use of personal protective equipment (PPE) for a resident, identified as R18, who was on enhanced barrier precautions due to conditions such as gangrene and methicillin-resistant Staphylococcus aureus infection. During a transfer from bed to wheelchair, two staff members, V11 and V12, wore gloves but did not don gowns as required by the facility's enhanced barrier precautions policy. The policy mandates the use of gowns and gloves during high-contact care activities to prevent the transfer of multidrug-resistant organisms (MDROs). The Director of Nursing (DON) confirmed that the facility's policy requires the use of gowns and gloves for residents on enhanced barrier precautions, especially during activities involving wounds or invasive devices. Despite clear signage and available PPE, the staff did not comply with these requirements, leading to a breach in infection control protocols.
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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.
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Nursing homes near Crystal Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Pines Rehab & Hcc | 1.8 mi | — | 4 | 0 |
| Pearl Of Crystal Lake, The | 3.1 mi | — | 0 | 0 |
| Ignite Medical Mchenry | 5.7 mi | — | 3 | 0 |
| Alden Terrace Of Mchenry Rehab | 6.8 mi | — | 5 | 0 |
| La Bella Of Woodstock | 7.3 mi | — | 12 | 0 |
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