Inspection Reports for Fair Oaks Senior Living
2200 W Liberty Ave, Pittsburgh, PA 15226, PA, 15226
Back to Facility Profile
Inspection Report
Complaint Investigation
Census: 76
Capacity: 100
Deficiencies: 2
Apr 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation at FAIR OAKS SENIOR LIVING on 04/30/2025.
Findings
Two deficiencies were found: windows and doors were not properly screened or secured, and the designated smoking area was not maintained safely with cigarette burn holes and debris. Plans of correction were accepted and implemented by 06/10/2025.
Complaint Details
The inspection was triggered by a complaint, as stated under Inspection Information with Reason: Complaint.
Deficiencies (2)
| Description |
|---|
| Windows and screens were missing on the side exit door near the administrator’s office and on operable windows in the marketing director’s office. |
| The designated smoking area had cigarette burn holes on the employee entrance ramp, ash and burn marks on the brick wall, and cigarette butts on the carpeting. |
Report Facts
License Capacity: 100
Residents Served: 76
Current Hospice Residents: 11
Residents Diagnosed with Mental Illness: 11
Residents Aged 60 or Older: 74
Residents with Mobility Need: 54
Residents Diagnosed with Intellectual Disability: 4
Residents with Physical Disability: 1
Total Daily Staff: 130
Waking Staff: 98
Inspection Report
Follow-Up
Census: 75
Capacity: 100
Deficiencies: 1
Mar 24, 2025
Visit Reason
The inspection visit occurred as a partial, unannounced review triggered by complaint and monitoring reasons on 03/24/2025.
Findings
The report found that medications and syringes were not properly locked, with a specific incident of unlocked medications accessible to a resident unable to self-administer medications. A plan of correction was accepted and implemented, including staff retraining and ongoing supervision.
Complaint Details
The inspection was complaint-related and monitoring in nature, but no substantiation status is explicitly stated.
Deficiencies (1)
| Description |
|---|
| Numerous medications for a resident were unlocked and accessible in a medication cup, violating the requirement that prescription medications, OTC medications, CAM, and syringes be kept locked. |
Report Facts
License Capacity: 100
Residents Served: 75
Current Hospice Residents: 11
Residents Age 60 or Older: 72
Residents with Mobility Need: 51
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 82
Capacity: 100
Deficiencies: 5
Dec 13, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident involving allegations of resident abuse.
Findings
The inspection found multiple violations related to resident abuse, failure to immediately report suspected abuse, inadequate supervision of a staff member accused of abuse, privacy violations due to video recording in common areas, and failure to provide resident records to a designated person. Plans of correction were directed and later implemented.
Complaint Details
The visit was complaint-related involving allegations of sexual abuse by a direct care staff person against a resident. The complaint was substantiated with evidence including video footage confirming the staff member's inappropriate conduct and failure to follow proper reporting and supervisory procedures.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Failure to immediately develop and implement a plan of supervision or suspend a staff person involved in an alleged abuse incident. |
| Resident was subjected to sexual abuse by a direct care staff person. |
| Video cameras recording in common areas including hallways where resident bedrooms are present, violating resident privacy. |
| Failure to provide resident records to the resident's designated person despite multiple requests. |
Report Facts
License Capacity: 100
Residents Served: 82
Current Hospice Residents: 4
Residents Age 60 or Older: 79
Residents with Mobility Need: 55
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Total Daily Staff: 137
Waking Staff: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Director of Clinical Services | Reported the allegation of sexual abuse and communicated with the accused staff member. |
| Staff person A | Direct Care Staff Person | Accused of sexual abuse towards a resident and failed to leave the facility immediately after the allegation. |
| Staff person C | Administrator | Reviewed video footage confirming the accused staff member's presence in the resident's bedroom after being told to leave. |
| Staff person D | Compliance Director | Reviewed video footage confirming the accused staff member's presence in the resident's bedroom after being told to leave. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 100
Deficiencies: 0
Aug 16, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit for complaint and monitoring purposes.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and included monitoring; no deficiencies or citations were found.
Report Facts
Residents Served: 82
License Capacity: 100
Current Residents in Hospice: 11
Residents Age 60 or Older: 81
Residents with Mobility Need: 30
Residents with Physical Disability: 3
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents Receiving Supplemental Security Income: 0
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 13
Jun 17, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit triggered by complaint, provisional, incident, and monitoring reasons.
Findings
Multiple deficiencies were identified including lack of resident rights documentation, insufficient first aid/CPR trained staff during certain shifts, unsanitary conditions in common areas, improper food storage and labeling, missing fire drills, medication storage and accountability issues, and incomplete resident assessments and support plan signatures. Plans of correction were accepted and implemented with follow-up audits and trainings scheduled.
Complaint Details
The inspection was complaint-related, with the reason including complaint, provisional, incident, and monitoring. The submitted plan of correction was determined to be fully implemented.
Deficiencies (13)
| Description |
|---|
| Resident #1's contract lacked the required list of resident rights and no addendum was attached. |
| Insufficient number of staff trained in first aid and CPR present during multiple shifts for 85-86 residents. |
| Pungent urine odor from a used urine-soaked adult brief found on the floor in the second-floor common shower room. |
| Use of common towels prohibited; two unlabeled washcloths and four unlabeled towels found on portable shower chair. |
| No thermometer inside small refrigerator and freezer in second-floor dining room; uncovered and unlabeled frozen orange liquid found. |
| Food not stored in closed or sealed containers; open unsealed bag of brown sugar and uncovered frozen orange liquid found. |
| Failure to conduct unannounced fire drills during August, September, and October 2023. |
| No previous sleeping hours fire drill indicated on fire drill log prior to 3/18/24. |
| Weekly menus not posted one week in advance; missing following week's menu. |
| Medication accountability issue: missing Morphine Sulfate doses unaccounted for; failure to verify amounts in prefilled syringes. |
| No documentation that resident #1 was educated on the right to question or refuse medication. |
| Resident #3 and #4 assessments did not indicate wheelchair use despite medical evaluations confirming use. |
| Resident #3's support plan was not signed by the resident and no indication resident was unable or unwilling to sign. |
Report Facts
Residents present: 86
License capacity: 100
Current hospice residents: 14
Residents aged 60 or older: 82
Residents with mobility need: 40
Residents with mental illness: 3
Residents with intellectual disability: 1
Staff total daily: 126
Waking staff: 95
Controlled doses received: 20
Controlled doses administered: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Care | Audited medication doses and ensured compliance with narcotic counts. | |
| Compliance Director | Conducted audits, scheduled trainings, and ensured ongoing compliance with regulations. | |
| Admin | Provided trainings, conducted audits, and implemented corrective actions. | |
| Director of Health Services | Responsible for scheduling staff trained in first aid and CPR. | |
| Kitchen Director | Trained on menu posting requirements. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 11
Apr 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation and fine, with an unannounced partial inspection on 04/12/2024 to review compliance and plan of correction implementation.
Findings
Multiple deficiencies were found related to resident personal equipment, sanitary conditions, lighting, medication storage and administration, medication records, prescriber order adherence, resident assessments, and support plans. Several repeat violations were noted. Plans of correction were accepted and fully implemented by 08/15/2024.
Complaint Details
The inspection was complaint-driven with a fine issued. The complaint involved concerns about medication administration, resident safety hazards, and sanitary conditions. The plan of correction was accepted and fully implemented.
Deficiencies (11)
| Description |
|---|
| Bedside mobility device in resident #1's room was loosely wrapped with a pillowcase creating an entanglement hazard. |
| Resident #2’s blood glucose reading was taken on resident #3’s glucometer, indicating sanitary condition issues. |
| Bedside lights in resident rooms #4, #5, and #2 were inoperable or had broken controls. |
| Glucometers for residents #2, #3, and #6 were not properly calibrated or set to correct date/time, and medication administration records had discrepancies. |
| Resident #5’s medication blister pack was opened and re-sealed with medical tape. |
| Resident #6’s medication administration record included duplicate entries for medication doses. |
| Resident #7’s medication was documented as administered twice daily despite orders to discontinue; medication was not found in the cart. |
| Multiple residents (#3, #5, #6, #8) had medication administration errors including missed doses, incorrect timing, and incomplete blood glucose monitoring. |
| Resident #9’s initial assessment did not include personal care needs related to bowel management. |
| Resident #1 and #7’s assessments did not document use of bedside mobility devices or enablers and related personal care needs. |
| Resident #1 and #10’s support plans did not document the correct bedside mobility devices or related personal care needs. |
Report Facts
Residents Served: 87
License Capacity: 100
Total Daily Staff: 119
Waking Staff: 89
Current Residents in Hospice: 11
Residents Age 60 or Older: 86
Residents Diagnosed with Mental Illness: 52
Residents with Mobility Need: 32
Residents with Physical Disability: 2
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Enforcement
Census: 87
Capacity: 100
Deficiencies: 23
Aug 17, 2023
Visit Reason
The inspection was conducted due to renewal, complaint, provisional license issuance, and incident investigation at Fair Oaks Senior Living.
Findings
Multiple violations were found including failure to post violation reports, delayed abuse reporting, record confidentiality breaches, resident abuse incidents, staff qualification deficiencies, training record issues, unsafe physical environment conditions, medication labeling and administration errors, incomplete resident assessments, and inadequate support plans. A third provisional license was issued with fines pending correction.
Complaint Details
The complaint investigation revealed incidents of resident abuse, failure to report abuse timely, inadequate supervision leading to resident injury, and deficiencies in resident assessments and support plans. The facility was found noncompliant with multiple regulatory requirements.
Deficiencies (23)
| Description |
|---|
| Violation reports dated 6/23/22 and 11/15/22 were not posted in the home. |
| Resident-to-resident abuse incident was not reported immediately to the local agency. |
| Resident records were unlocked, unattended and accessible to unauthorized persons. |
| Resident requiring secured dementia care unit was admitted without proper supervision, resulting in abuse. |
| Direct care staff lacked required high school diploma, GED, or active registry status. |
| Direct care staff did not receive required dementia and cognitive impairment training. |
| Training records lacked required details such as location, content, date, and source. |
| Resident's hearing impairment accommodation phone was not set up. |
| Poisonous materials were unlocked and accessible to residents. |
| Bathroom exhaust fan was inoperable. |
| Hot water temperature exceeded 120°F. |
| Emergency exit door screens were torn or detached. |
| No handrail for laundry room emergency exit step. |
| Toilet and sink in women's common bathroom were not functioning properly. |
| Resident bedside lamp was not within reach or not working. |
| Emergency exit door was locked with keypad without posted code, restricting egress. |
| Evacuation diagram was inaccurate after building renovation. |
| Medication labels did not match orders or were incomplete. |
| Blood glucose readings were not recorded properly on medication administration record. |
| Medication record did not include all prescribed medications. |
| Medications were not administered as prescribed and found in medication cart. |
| Resident assessment did not reflect accurate diagnoses or behavioral issues. |
| Resident support plan did not address use of bedrails or mobility devices. |
Report Facts
License Capacity: 100
Residents Served: 87
Fines Calculated: 261
Fines Calculated: 435
Staffing: 105
Waking Staff: 79
Residents with Mobility Need: 27
Residents with Mental Illness: 1
Inspection Report
Complaint Investigation
Census: 78
Capacity: 100
Deficiencies: 23
Aug 17, 2023
Visit Reason
The inspection was conducted due to a combination of renewal, complaint, provisional, and incident reasons, including multiple licensing inspections over several dates.
Findings
Multiple violations were found related to resident abuse, failure to report abuse timely, confidentiality breaches, inadequate staff qualifications and training, environmental hazards, medication labeling and administration errors, and deficiencies in resident assessments and support plans.
Complaint Details
The complaint investigation revealed incidents of resident abuse, failure to report abuse timely, elopement risk management failures, and multiple deficiencies in resident care and documentation.
Deficiencies (23)
| Description |
|---|
| Violation reports dated 6/23/22 and 11/15/22 were not posted in the home. |
| Resident-to-resident abuse incident was not reported immediately as required. |
| Resident records were unlocked, unattended and accessible to unauthorized persons. |
| Resident admitted requiring secured dementia care unit (SDCU) was not properly supervised and caused harm to another resident. |
| Direct care staff person lacked required high school diploma, GED, or active nurse aide registry status. |
| Direct care staff did not receive required dementia and cognitive impairment training. |
| Training records lacked required details such as location, content, date, and source. |
| Resident's hearing impairment accommodation device was not set up or used. |
| Poisonous materials were unlocked and accessible to residents. |
| Bathroom exhaust fan was inoperable. |
| Hot water temperature exceeded 120°F. |
| Emergency exit door screens were torn or detached. |
| No handrail for laundry room emergency exit step. |
| Toilet and sink in lower-level women's bathroom were not functioning properly. |
| Resident's bedside lamp was not within reach or not working. |
| Emergency exit door was locked with keypad without posted code, restricting egress. |
| Evacuation diagram was inaccurate after building renovation. |
| Medication labels did not match orders or were incomplete. |
| Blood glucose reading was not documented on medication administration record. |
| Medication was missing from medication administration record. |
| Medications were not administered as prescribed and found in medication cart. |
| Resident assessment did not reflect accurate diagnoses or behavioral issues. |
| Resident support plan did not address use of bedrails or mobility devices. |
Report Facts
License Capacity: 100
Residents Served: 78
Staffing Hours: 105
Waking Staff: 79
Deficiency Counts: 23
Fine Amount: 261
Fine Amount: 435
Correction Dates: 15
Correction Dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 100
Deficiencies: 22
Aug 17, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, provisional, and incident investigation to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including failure to post violation reports, delayed abuse reporting, record confidentiality breaches, resident abuse, staff qualification issues, training deficiencies, unsafe physical conditions, medication labeling and administration errors, and incomplete resident assessments and support plans.
Complaint Details
The complaint involved allegations of resident abuse, failure to report abuse timely, inadequate supervision leading to resident injury, and deficiencies in resident care plans and medication administration. The complaint investigation found substantiated violations including resident elopement resulting in injury and failure to maintain proper supervision and safety measures.
Deficiencies (22)
| Description |
|---|
| Violation reports dated 6/23/22 and 11/15/22 were not posted in the home. |
| Resident-to-resident abuse incident was not immediately reported to the local area agency on aging. |
| Resident records were unlocked, unattended and accessible to unauthorized persons. |
| Resident requiring secured dementia care unit (SDCU) was admitted without proper supervision and caused harm to another resident. |
| Direct care staff person did not have required high school diploma, GED, or active nurse aide registry status. |
| Direct care staff did not receive required dementia and cognitive impairment training. |
| Training records lacked required details including location, content, date, and source. |
| Resident's hearing impairment accommodation device was not set up. |
| Poisonous materials were unlocked and accessible to residents. |
| Bathroom exhaust fan was inoperable. |
| Hot water temperature exceeded 120°F. |
| Emergency exit door screens were torn or detached. |
| No handrail for laundry room emergency exit step. |
| Toilet and sink in women's common bathroom were not functioning properly. |
| Resident bedside lamp was not within reach or not working. |
| Emergency exit door was locked with keypad without posted code, restricting egress. |
| Evacuation diagram was inaccurate after building renovation. |
| Medication labels did not match orders or were incomplete. |
| Blood glucose readings were not documented properly. |
| Medication administration errors including missed doses and incorrect administration. |
| Resident initial assessments and support plans were incomplete or inaccurate. |
| Resident support plan did not address use of bedrails or mobility devices. |
Report Facts
License Capacity: 100
Residents Served: 78
Staffing Hours: 105
Waking Staff: 79
Number of Violations: 22
Fine Amount: 261
Fine Amount: 435
Residents Served: 83
Residents Served: 87
Total Daily Staff: 120
Waking Staff: 90
Inspection Report
Complaint Investigation
Census: 71
Capacity: 100
Deficiencies: 16
May 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation with provisional and fine reasons, including a review of a submitted plan of correction.
Findings
Multiple deficiencies were found including breaches in record confidentiality, incomplete criminal background checks, inadequate first aid/CPR training, missing staff orientations, unsafe resident personal equipment, improper trash management, water damage in facility, lack of proper hearing impairment accommodations, incomplete medical evaluations, smoking policy violations, unsecured medications, medication administration errors, and incomplete resident support plans.
Complaint Details
The visit was complaint-related, provisional, and included a fine. The submitted plan of correction was reviewed and found fully implemented.
Deficiencies (16)
| Description |
|---|
| Multiple resident records were unlocked, unattended, and accessible in the administrator's office. |
| Criminal history background checks were not completed timely for several staff members. |
| Inadequate staff trained in first aid and CPR present for every 50 residents on multiple dates. |
| Ancillary staff did not receive required orientation on fire safety, emergency preparedness, and job functions timely. |
| An uncovered enabler bar on a resident's bed posed a potential entrapment hazard. |
| Dumpster outside the home was overflowing and could not fully close for several hours. |
| Ceiling tiles in the Lemon Room had dry water damage and damp spots. |
| Resident with hearing impairment lacked a signaling device approved by a fire safety expert. |
| Resident's initial medical evaluation form was missing the medical professional's license number. |
| Resident was observed smoking outside the designated smoking area contrary to home rules. |
| Multiple medications and ointments were unlocked, unattended, and accessible in resident rooms and bathrooms. |
| Medications without current orders were found in resident rooms and medication carts. |
| Medications were stored without proper dating after opening and expired medications were present. |
| Controlled medication count sheets were inaccurate and incomplete. |
| Medication administration records (MARs) had errors including incorrect frequency, missing staff initials, and missed doses. |
| Resident support plans were not updated to reflect current care needs and services. |
Report Facts
License Capacity: 100
Residents Served: 71
Current Residents in Hospice: 7
Staffing Hours - Total Daily Staff: 89
Staffing Hours - Waking Staff: 67
Ceiling Tiles Damaged: 7
Medication Errors: 16
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 20
Nov 15, 2022
Visit Reason
The inspection was conducted as a complaint investigation and provisional licensing review for Fair Oaks Senior Living.
Findings
Multiple violations were found including delayed assistance with activities of daily living, unsigned resident contracts, incomplete criminal background checks, inadequate staffing hours during waking hours, missing emergency telephone numbers, missing bedside tables and operable lamps, improper soap dispensers and towels, lack of documentation for fire safety inspections and drills, incomplete medical evaluations, dietary needs not met, medication storage and availability issues, and incomplete resident assessments and support plans.
Complaint Details
The inspection was complaint-driven and included a provisional licensing review. Multiple repeat violations were noted.
Deficiencies (20)
| Description |
|---|
| Resident #1 waited over 1 hour for assistance with activities of daily living on multiple occasions. |
| Resident #2's resident-home contract was not signed by the resident. |
| Criminal background check was not completed for staff member A. |
| Direct care staff member A did not have required qualifications. |
| Insufficient direct care staffing hours during waking hours on 11/5/22. |
| Emergency telephone numbers were not posted on or near the telephone in resident #1's bedroom. |
| Resident #5 did not have a bedside table or shelf. |
| Resident #5 did not have an operable lamp or other source of lighting at bedside. |
| Unlabeled bar of soap present in shared bathroom of residents #3 and #4. |
| Used, unlabeled towel present in shared bathroom of residents #3 and #4; no sanitary hand drying means present. |
| Lack of documentation for prior fire safety inspection and fire drill; unable to determine timeliness. |
| Evacuation times during fire drills exceeded the time specified by fire safety expert. |
| Resident #6's medical evaluation did not include ability to self-administer medications; Resident #7's evaluation missing multiple sections. |
| Resident #6 was served a regular diet instead of prescribed mechanical soft diet from 11/15/22 to 11/17/22. |
| Only one menu posted for the week of 11/11/22 through 11/19/22; no menu posted one week in advance. |
| Unlocked, unattended vitamins found in resident #8's bedroom. |
| Resident #3's prescribed medication Lorazepam was not available for administration; resident #9's glucometer not set to correct time. |
| Resident #1's assessment inaccurately indicated assistance needs for toileting; Resident #3's assessment inaccurate for transfer assistance; Resident #10's assessment incomplete for eating and drinking. |
| Resident #2's assessment did not reflect prescribed puree diet. |
| Resident #1's support plan did not indicate use of wheeled walker; Resident #3's support plan missing hospice service details and transfer assistance; Resident #10's support plan missing catheter and Hoyer lift use. |
Report Facts
Residents served: 83
Licensed capacity: 100
Staffing hours during waking hours: 70.62
Required staffing hours during waking hours: 73.5
Number of delayed call bell responses: 7
Fine per day: 415
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the licensing letter |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 100
Deficiencies: 14
Jun 23, 2022
Visit Reason
The inspection was conducted as a complaint investigation with multiple on-site visits between June and December 2022 to assess compliance with Pennsylvania Personal Care Homes regulations.
Findings
The facility was found to have multiple violations including medication errors, misuse of resident funds, delayed assistance with activities of daily living, inadequate staffing hours, missing medical evaluations and assessments, improper medication storage and administration, and failure to follow prescriber's orders. Plans of correction were submitted but many were not implemented as of the last follow-up.
Complaint Details
The inspection was complaint-driven with multiple visits and follow-ups. The complaint involved medication errors, misuse of resident funds, inadequate care, and documentation deficiencies. Substantiation status is not explicitly stated.
Deficiencies (14)
| Description |
|---|
| Medication errors were not reported to the Department and medications were unavailable leading to missed doses. |
| Staff member borrowed money from a resident and failed to provide ordered supplies. |
| Resident experienced excessive wait times for assistance with activities of daily living. |
| Staff member exhibited disrespectful behavior towards residents. |
| Insufficient direct care staffing hours provided for residents with mobility needs. |
| Medical evaluations and assessments were not completed timely for several residents. |
| Resident self-administration of medication was not properly assessed or documented. |
| Medications were not available in the home due to pharmacy delivery failures. |
| Medication administration documentation was incomplete or missing. |
| Failure to follow prescriber's orders resulting in missed medication doses. |
| The home's description of services did not reflect provision of catheter care despite residents requiring it. |
| Preadmission screening was completed outside the required timeframe. |
| Initial assessments and support plans were not completed within required timeframes. |
| Support plans were not signed by residents or properly documented. |
Report Facts
Residents served: 73
License capacity: 100
Residents with mobility needs: 23
Medication errors: 2
Fine per violation per day: 5
Total fine per violation per day: 415
Excessive wait times: 6
Direct care staffing hours required: 93
Direct care staffing hours provided: 83.75
Direct care staffing hours required: 91
Direct care staffing hours provided: 90
Waking hours staffing required: 69.75
Waking hours staffing provided: 69.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the enforcement letter |
| Health Services Director | Named as responsible for medication errors reporting and resigned on 05/27/22 | |
| Administrator | Involved in oversight, reporting incidents, and implementing corrective actions | |
| Staff person D | Involved in misuse of resident funds and described as disrespectful to residents |
Inspection Report
Census: 54
Capacity: 100
Deficiencies: 8
Mar 18, 2022
Visit Reason
The inspection was an unannounced partial inspection conducted for an interim reason, including multiple visits on November 1, 2, 3, 2021 and March 18 and 21, 2022, to assess compliance with Pennsylvania Department of Human Services regulations for Personal Care Homes.
Findings
Multiple violations were found related to medication management, storage procedures, confidentiality, and record keeping. The facility's certificate of compliance was revoked and replaced with a first provisional license based on an acceptable plan of correction. Several deficiencies were noted with plans of correction proposed but not yet implemented as of the report date.
Deficiencies (8)
| Description |
|---|
| Resident records were not kept confidential; narcotic books for medication carts were unlocked and unattended. |
| Direct care staff provided unsupervised ADL services without completing required direct care training and competency testing. |
| Food served and returned from an individual's plate was not labeled or dated; leftover hot dogs were found unsealed and undated. |
| Refrigerator temperature measured 50 degrees Fahrenheit, exceeding required maximum of 40°F. |
| Prescription medications and syringes were found unlocked and unsecured in a resident's room, including a bottle of Nitrostats not labeled. |
| Medication administration records were incomplete or inaccurate, including unaccounted syringes and missing blood glucose readings. |
| Medication errors including incorrect signing off on medication sheets and failure to follow prescriber's orders for insulin administration. |
| Shift-to-shift narcotic sign-off sheets contained errors and lacked proper documentation. |
Report Facts
License Capacity: 100
Residents Served: 54
Staff: 63
Waking Staff: 47
Current Hospice Residents: 4
Medication Syringes Count: 10
Hot Dogs Count: 20
Nitrostat Tablets: 25
Inspection Report
Renewal
Census: 54
Capacity: 100
Deficiencies: 24
Nov 1, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of Fair Oaks Senior Living to assess compliance with applicable regulations and licensing requirements.
Findings
Multiple violations were found related to compliance with health and safety laws, privacy, criminal background checks, training records, sanitary conditions, trash management, surfaces, water pressure, furniture and equipment, lighting, walls, food protection, medication administration, storage procedures, medication records, and additional assessments. Some plans of correction were implemented while others were not.
Deficiencies (24)
| Description |
|---|
| Influenza information poster was not posted in a public and conspicuous place in the home. |
| Department's poster of resident rights and rights violated poster was not posted in a conspicuous place. |
| No lock on the door to ensure privacy in the Community Shower room on the second floor of Oak Hall. |
| Criminal background check was not requested or completed for direct care staff person B. |
| Homes record for direct care staff person B did not include documentation of completion of Department-approved training and competency test. |
| Approximately 1/4" layer of dust and dirt on air vent in private bathroom of bedroom #101. |
| Trash can at front entrance did not have a lid and was overflowing with trash. |
| Slight ramp in floor at entrance of Community Shower Room with missing and broken tiles. |
| No hot water at kitchenette sink in dining room of Oak Hall on second floor. |
| Small recess light in ceiling above microwave in dining room had no light cover or bulb. |
| Bedside lamp for resident #6 was inoperable and had no source of light that could be turned on/off from bedside. |
| Crack approximately 8" long in ceiling by door of private bathroom of bedroom #101 with water marks. |
| Three uncovered chocolate cream pies stored in walk-in cooler in kitchen. |
| Outdated or spoiled food found in walk-in freezer including partially full bags of chicken breast cutlets. |
| Resident #2 had multiple OTC medications stored in multiple areas of the bedroom not indicated for self-administration and not stored securely. |
| Medication administration errors including medications not assessed for self-administration, missed doses, and improper documentation. |
| Large metal cabinet with glass doors in hallway to nurse's station was unlocked and accessible with multiple medical supplies and medications. |
| Loose medication tablets found in med cart drawers with inability to identify medication or owner. |
| Medication audit discrepancies and unaccounted medication amounts for resident #5. |
| Blood glucose readings not verified due to deleted history in resident records. |
| Medication record did not include diagnosis or purpose for several medications for residents #2, #3, #4, and #5. |
| Medication administration times and documentation were incomplete or inaccurate for resident #2 and others. |
| Follow prescriber's orders violations including incorrect insulin administration and documentation. |
| Resident #5's assessment was not updated to reflect significant changes in care needs and services. |
Report Facts
Inspection Dates: 3
Residents Served: 54
License Capacity: 100
Staffing Hours: 69
Waking Staff: 52
Current Hospice Residents: 4
Residents Age 60 or Older: 53
Residents with Supplemental Security Income: 9
Residents with Mobility Need: 15
Medication Tablets Count: 24
Medication Tablets Count: 8
Inspection Report
Re-Inspection
Census: 51
Capacity: 100
Deficiencies: 2
Aug 25, 2021
Visit Reason
The inspection was conducted due to a change in legal entity and as a partial licensing inspection of the newly licensed facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the inspection was partial because the new legal entity was recently established. Two deficiencies were cited related to improper storage of poisonous materials and missing current rabies vaccination records for a visiting dog.
Deficiencies (2)
| Description |
|---|
| A 29-ounce spray bottle containing sanitizer was stored without original manufacturer labeling in the main kitchen utility closet. |
| The facility did not have a current rabies vaccination certificate on file for a visiting dog named Fattie; the vaccination on record expired on 3/10/18. |
Report Facts
License Capacity: 100
Residents Served: 51
Current Hospice Residents: 4
Total Daily Staff: 66
Waking Staff: 50
Residents with Mobility Need: 15
Residents 60 Years or Older: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed the licensing inspection letter and certificate. |
Loading inspection reports...
