Fair Oaks Healthcare: Staff Unaware of Abuse Complaint - CA
The incident occurred on August 25 when CNA 4 was changing Resident 1's brief while a family member was present in the room. The family member later complained that the nursing assistant had been rough with the resident during the personal care.
Fair Oaks Healthcare Center's Director of Nursing acknowledged during the September 10 inspection that neither the resident nor the accused nursing assistant had been interviewed about the incident. The DON stated the facility had investigated and followed up by removing CNA 4 from working with Resident 1.
But CNA 4 told a different story.
During a telephone interview with inspectors at 12:50 p.m. on September 10, CNA 4 confirmed she had worked the evening shift on August 25 and that Resident 1 was assigned to her care. She stated she changed the resident's brief while the family member was present in the room.
When inspectors asked if Resident 1 had stated she was in pain during the diaper change, CNA 4 said she would have stopped the procedure if the resident had expressed pain. But when asked whether the facility had notified her of Resident 1's complaint about rough treatment, CNA 4 revealed the breakdown in the facility's investigation process.
"She was not aware of any complaints," inspectors documented. CNA 4 told them, "This is the first time I heard about it."
The nursing assistant also contradicted the Director of Nursing's claim about her work assignment. "No one told me I wouldn't work on that wing," CNA 4 stated.
The facility's own grievance policy, revised in April 2017, requires prompt investigation and communication with all parties involved. The policy states that residents and their representatives have the right to file grievances either orally or in writing to facility staff, and that administrators and staff will make prompt efforts to resolve grievances.
According to the policy, any resident, family member, or appointed representative may file a grievance concerning care, treatment, or staff members. All such complaints will be considered, and actions will be responded to in writing with rationale for the response.
The policy specifically outlines investigation procedures. Upon receipt of a complaint, the grievance officer must review and investigate the allegations and submit a written report to the administrator within five working days. The resident or person filing the complaint must be informed both verbally and in writing of the investigation findings and any corrective actions.
Most critically, the administrator or designee must make oral reports within a specified number of working days, and provide a written summary of the investigation to the resident with a copy filed in the business office.
None of this happened with CNA 4.
The nursing assistant worked her regular shifts for two weeks after the complaint was filed, unaware that a family member had accused her of rough treatment during personal care. She continued caring for residents throughout the facility, including potentially on the same wing where the incident occurred, despite management's claim that she had been removed from working with Resident 1.
The facility's failure extended beyond just the accused employee. Inspectors found that Resident 1 was never interviewed about the family member's complaint of rough treatment during the diaper change. The resident's own account of what happened during the personal care procedure was never documented or considered in the facility's purported investigation.
Federal inspectors cited Fair Oaks Healthcare Center for failing to ensure that residents could voice grievances without discrimination or reprisal, and for not investigating and resolving complaints in accordance with state and federal requirements. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The citation reveals a facility that claimed to investigate a serious allegation of rough treatment but failed to follow its own written policies. While management told inspectors they had taken corrective action by reassigning the nursing assistant, the employee herself was never informed of the complaint, never given an opportunity to respond to the allegations, and apparently never actually restricted from working with any residents.
The breakdown left a family member's serious concerns about rough treatment unresolved, a resident's perspective unheard, and a nursing assistant working for two weeks without knowing she faced allegations of improper care. Only when federal inspectors arrived to investigate the complaint did the full scope of the facility's investigative failures become clear.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair Oaks Healthcare Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
FAIR OAKS HEALTHCARE CENTER in FAIR OAKS, CA was cited for abuse-related violations during a health inspection on September 10, 2025.
The incident occurred on August 25 when CNA 4 was changing Resident 1's brief while a family member was present in the room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.