Fairwinds - Woodward Park

Provide resident hot water for personal care

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidcene by: LPA observation and interviews completed, the licensee did not comply with the section cited above in that water temperatrures tested in rooms (W132, W326, W328, W330) tested below the required 105 degrees F to 120 degrees F. This poses an immediate health, safety and or personal rights risk to residents in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 5 resident's current medical assessment and TB test documentation was not available which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above due to staff members not having current training in areas, which poses an immediate health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 6 bedrooms were observed with chemicals, disinfectants, cleaning solutions. Bedroom is shared by a couple and 602 review revealed R1 is not allowed to have access to chemicals/ medications. Bistro area had chemicals in unlocked cabinets and housekeeping cart was unlocked in the hallway with chemicals which poses an immediate health, safety or personal rights risk to persons in care.

RCFE complaint poster posting requirements

Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) was not posted in the main entryway of the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above due to some staff members not having current training in certain areas, which poses a potential health, safety or personal rights risk to persons in care.

Kitchen sanitation against contamination sources

Based on observation, the licensee did not comply with the section cited above due to kitchen cabinets having debris, ice cream not being stored properly, defrosting food should be stored to prevent contamination. which poses/posed a potential health, safety or personal rights risk to persons in care.

Cool occupied rooms to regulated temperature range

87303(b)(2) Maintenance and Operation(b) A comfortable temperature for residents shall be maintained at all times.(2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.This requirement is not met as evidenced by: Based on LPAs observations, interview, and record reviews, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed various thermostats which did not show AC to be working properly. LPA conducted various interviews which stated facility took 7 days or longer to repair AC units in apartments.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: LPA found that on 6/5/22, R1's medication Ciprofloxacin 500 mg Tabs (Take 1 tablet orally two times daily) were given three times at the times of 8:10 AM, 5:37 PM, and 7:22 PM. On 6/7/22, the facility received new Amlodipine 5mg (Take 1 tablet orally daily) from the pharmacy some time in the evening of the day and S1 administered a dose the same evening after finding that the new medication was received and in the med room. The facility had already given the medication Amlodipine 10mg (Take 1 tablet orally daily) earlier that day at 6:30 AM. LPA found that the facility did not receive the doctor's order for the change in dosage for the medication until 6/8/22. LPA found that R1's medication bubble pack Amlodipine 10mg that was filled on 4/21/22 to be started 5/1/22 and the bubble pack Amlodipine 10 mg that was filled on 5/20/22 to be started 5/29/22 was recorded on the Centrally Stored Medication sheet and in the facility's internal digital medication administration log as given, but both bubble packs were still intact and full without any doses administered. Which poses a potential health and personal rights risk to resident in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by: CCL received a faxed incident report on 6/20/22 for an incident that occurred on 6/10/22 and the facility sent an incident report to CCL on 6/23/22 for an incident that occurred on 6/7/22, which poses a potential health, safety, or personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: LPA found that the main AC unit in the kitchen is currently turned off to prevent the AC water pipe leak that recently occurred. Facility is waiting for HVAC company to schedule the appointment for service on the AC water pipe leak to be able to turn water back on for the AC, which poses a potential health and safety risk to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by: CCL received a SIR on 5/20/22 reporting 12 positive persons. Of the total 12 reported positive persons, 1 resident tested positive on 4/29/22, 1 staff tested positive on 5/6/22, 1 resident tested positive on 5/10/22, and 1 resident tested positive on 5/12/22, which poses a potential health, safety, or personal rights risk to residents in care.

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.This requirement is not met as evidenced by: Based on interviews and records review, LPA found that the facility overcharged the resident $9408. R1 was charged for services that R1 did not agree to receiving and the facility could not produce documents to show R1 agreed to services. This poses an immediate personal rights risk to residents in care.