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Deficiency Records for Fair Oaks Healthcare Center
A list of the most recent deficiencies for Fair Oaks Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Fair Oaks Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-16 | 2024-07-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-06 | 2024-07-09 | Y |
| Ensure a qualified health professional conducts resident assessments. | Health | 2024-06-06 | 2024-07-09 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-06 | 2024-07-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-06 | 2024-07-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-06 | 2024-07-09 | Y |
| Provide appropriate foot care. | Health | 2024-03-21 | 2024-04-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-21 | 2024-04-17 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-03-21 | 2024-04-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-17 | 2024-02-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-17 | 2024-02-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-29 | 2024-02-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-08 | 2024-02-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-30 | 2023-11-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-05 | 2023-07-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-05 | 2023-07-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-05 | 2023-07-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-12 | 2023-05-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-12 | 2023-05-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-04 | 2023-04-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-30 | 2023-03-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-06 | 2022-08-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-19 | 2022-05-05 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-09 | 2021-12-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-04 | 2021-12-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-04 | 2021-12-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-04 | 2021-12-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2021-12-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-04 | 2021-12-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-04 | 2021-12-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-04 | 2021-12-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-04 | 2021-12-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2021-12-03 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-24 | 2019-05-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-22 | 2019-04-30 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-22 | 2019-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-22 | 2019-04-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-22 | 2019-04-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-02-22 | 2019-04-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-02-22 | 2019-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-22 | 2019-04-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-22 | 2019-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-22 | 2019-04-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-23 | 2018-04-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-23 | 2018-04-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-02-23 | 2018-04-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-02-23 | 2018-04-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-02-23 | 2018-04-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-02-23 | 2018-04-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-02-23 | 2018-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-23 | 2018-04-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-02-27 | 2018-03-14 | N |
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