A list of the most recent deficiencies for Fair Oaks Health Care 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-20 | 2024-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-20 | 2024-03-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-30 | 2023-07-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-30 | 2023-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-30 | 2023-07-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-25 | 2023-07-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-25 | 2023-07-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-05-25 | 2023-07-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-05-25 | 2023-06-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-10 | 2023-06-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-10 | 2023-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-10 | 2023-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-06-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-10 | 2023-06-16 | 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 | 2023-05-10 | 2023-06-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-10 | 2023-06-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-05-10 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-10 | 2023-06-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-30 | 2022-08-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-08 | 2022-07-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-08 | 2022-07-10 | 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 | 2022-06-08 | 2022-07-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-08 | 2022-07-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-08 | 2022-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-08 | 2022-07-05 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-08-27 | 2021-10-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-08-27 | 2021-09-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-04 | 2021-09-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-04 | 2021-09-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-04 | 2021-09-01 | 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 | 2021-08-04 | 2021-09-01 | N |
