FAIR OAKS HEALTH SYSTEMS, LLC

Nursing Home Inspector

1 SPARKS AVENUE
JAMESTOWN, KY 42629
Russell County
Phone: 270-343-2101
Provider Number: 185286
Last Inspection: 09/22/2016

About the Nursing Home

Number of Beds: 114
Number of Residents: 109
Beds Available: 5
Percent Occupancy: 96%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

9

Facility
9

County
12

KY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

9

2016
39

2015
4

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/22/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Potential 3 10/21/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/21/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/21/2016
 

8/14/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 9/10/2015
 
Failed To: Provide activities to meet the interests and needs of each resident. Isolated : Minimal 3 9/10/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 9/10/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 9/10/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/10/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/10/2015
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 9/11/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 9/10/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 9/10/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/10/2015
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 9/10/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 9/10/2015
 

7/24/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 8/15/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

9/14/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 10/6/2015
 

4/24/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 5/15/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg KY State Avg
Number of Residents 109 109.00 79.68
Registered Nurses 0.89 0.89 0.86
Licensed Practical / Vocational Nurses 0.69 0.69 0.87
Certified Nursing Assistants 2.53 2.53 2.40
Total Staff Hours 4.11 4.11 4.13

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% KY State Avg%
of high risk long-stay residents with pressure ulcers 3 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 98 98 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 98 95
of long-stay residents experiencing one or more falls with major injury 4 4 3
of long-stay residents who have depressive symptoms 7 7 2
of long-stay residents who lose too much weight 6 6 7
of long-stay residents who received an antianxiety or hypnotic medication 20 20 31
of long-stay residents who received an antipsychotic medication 21 21 19
of long-stay residents who self-report moderate to severe pain 3 3 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 13 13 21
of long-stay residents whose need for help with daily activities has increased 15 15 16
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 0 0 4
of low risk long-stay residents who lose control of their bowels or bladder 58 58 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 84 84 84
of short-stay residents who had an outpatient emergency department visit 13 13 14
of short-stay residents who newly received an antipsychotic medication 5 Not Available   59
of short-stay residents who self-report moderate to severe pain 16 5 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 89 16 16
of short-stay residents who were rehospitalized after a nursing home admission 9 89 83
of short-stay residents with pressure ulcers that are new or worsened 3 9 22