Inspection Reports for
Fairwinds – Sand Creek

.300.01 Licensed Registered Nurse (RN): the facility nurse confirmed they did not conduct 90-day assessments for six of eight sampled residents to include physical evaluation of systems such as breath sounds or skin integrity (previously cited 4/27/2022).

.310.01.g Medication Distribution System: several residents did not have their prescribed medications available, including PRN diclofenac sodium, acetaminophen, ondansetron, lidocaine patch, and others; the facility nurse stated she was unaware and will reorder the medications.

.310.02.f Discontinued and Expired Prescriptions: the medication destruction log lacked two signatures for each medication, documenting only one signature for non-narcotic medications; the nurse stated she understood only narcotic destruction required a witness.

.310.04.e Psychotropic or Behavior Modifying Medication: residents were taking psychotropic medications longer than six months without six-month medication reviews; the facility nurse confirmed reviews were not completed (previously cited 4/27/2022).

.320.01 Use of Negotiated Service Agreement: residents' NSAs did not clearly reflect needs or describe services, missing money management, night needs, emergency evacuation, wound care instructions, and hospice election documentation; the nurse stated the care team did not believe some needs were required and NSAs were not updated (previously cited 11/29/2017 and 4/27/2022).

.330.04.c.vii Resident Care Records: assessments for changes in physical and mental conditions were not consistently documented for six of eight sampled residents despite the nurse stating assessments were made.

.155.01 Relocation agreements: the facility could not provide the written agreements for the two required locations.

.155.03 Emergency generators: emergency power supply system generator sets shall be maintained in accordance with NFPA 110; no documented monthly load testing was provided (previously cited 4/24/2023).

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: dampers were not inspected within the last four years (previously cited 4/24/2023); only three spare 155-degree sprinkler pendants were available instead of six; escutcheon was missing from a flush mounted sprinkler pendant in the Assisted Living dining room.

.405.01.a Electrical installations and equipment: multi-plug adapters were used in rooms 100, 122, and 126 to supply power to devices such as chargers, lamps, clocks, and an air purifier, which is prohibited.

.405.02.a Prohibited applications: relocatable power taps were used to supply power to medical devices, including an oxygen concentrator in room 126 and a portable oxygen concentrator in room 115, which is prohibited.

.410 Requirements for emergency actions and fire drills: emergency egress and relocation drills shall be conducted at least six times a year on a bi-monthly basis; drills had a gap from June 2024 to October 2024 (previously cited 4/24/2023).

.155.03 Emergency generators: Emergency Power Supply System (EPSS) generator sets lacked documented monthly load testing, weekly inspections, and a four-hour load test for level 1 system.

.404 Fire and life safety standards: suppression systems lacked documented full trip testing since 2019; missing escutcheon and blocked pendant in storage; fire dampers not tested in past four years; fire doors not tested annually; emergency lighting testing not documented; alcohol-based hand rub dispensers not tested on refill; staff training documentation missing (previously cited 8).

.405.01 Electrical installations and equipment: HVAC equipment missing coverings; open junction box in IT closet; missing switch cover in maintenance closet (corrected on site).

.405.01.a Electrical installations and equipment: extension cords and multiple plug adapters prohibited but used to supply power to a coffee maker in Health and Wellness office.

.405.02.c Prohibited applications: relocatable power taps used to supply power to mini-fridge and microwave by housekeeping.

.405.03 Medical gases: no documented ongoing education program for staff on oxygen risks; no documented policy for elimination of ignition sources and misuse of flammable substances.

.410 Requirements for emergency actions and fire drills: drills conducted only four times in past twelve months with a four-month gap; only one drill during night shift when residents sleep.

.215.01 Administrator Responsibility: the administrator did not ensure a policy and procedure for abuse, neglect and exploitation was developed and implemented, missing components such as definitions, notification procedures, resident protections, and interventions; Adult Protection was not notified following an alleged exploitation incident and residents were not protected from further abuse.

.215.07 Notification to Adult Protection and Law Enforcement: the administrator did not notify adult protection and law enforcement after an alleged theft incident reported by a resident and confirmed the failure to notify.

.300.01 Licensed Registered Nurse (RN): the facility nurse did not conduct complete 90-day assessments for all sampled residents, missing physical evaluations such as breath sounds and skin integrity.

.305.02.b Current Medication Orders and Treatment Orders: the facility did not ensure residents received medications and treatments as ordered, including an incorrect dose given and failure to provide physician-ordered diet and medication for a resident (previously cited 11/29/2017).

.305.03 Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including pressure injuries not assessed for two residents.

.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not have current six-month psychotropic medication reviews with behavior updates for residents taking such medications.

.319.04 Maladaptive Behaviors: the facility did not evaluate behaviors for a resident who repeatedly yelled and slapped another resident, with no assessments prior to admission or after exhibited behaviors.

.320.01 Use of NSA: residents' Negotiated Service Agreements did not clearly reflect needs or describe services, missing elements such as money management, shopping, night needs, emergency evacuation, wound care, bathing, toileting, and incontinent care (previously cited 11/29/2017).

.330.04.c.iii Resident Care Records: medication technicians did not document assistance with medications and treatments, including failure to document oxygen saturation and blood glucose levels multiple times.

.330.06.b Behavior Documentation: the facility did not develop a behavior plan with at least one intervention for each maladaptive behavior.

.330.06.c Behavior Documentation: the facility documented behaviors but did not document incidents of a resident slapping and yelling at another resident despite multiple staff reports.

.645.01.a Training Requirements: four of seven medication technicians did not have documentation of an Idaho Board of Nursing approved medication assistance course in their employee records.

.215.08.b. Investigation within Thirty Days: the administrator did not conduct an investigation within 30 days when residents experienced falls, including Resident #1 with 13 falls and Resident #4 with 16 falls between September 2021 and January 2022; no investigations were documented.

.215.08.f. Notification to Licensing Agency within One Business Day: the facility did not notify Licensing and Certification within one business day when residents experienced falls requiring hospital assessment on multiple dates including 7/20/21, 7/21/21, 7/25/21, 8/25/21, 9/27/21, and when a resident fell and fractured ribs on 10/24/21.

.335.02. Standard Precautions: the facility did not follow public health district or CDC recommendations to prevent transmission of infectious disease; staff and management were observed wearing masks improperly between 1/5/22 and 1/6/22.

.600.04.a. Sufficient Personnel: the facility did not schedule sufficient staff during all hours; one care staff was scheduled on night shift for two floors with 53 residents, and multiple residents and eleven staff stated staffing was insufficient to meet needs.

.404 Fire and life safety standards for existing buildings: staff training on oxygen safety was not documented, weekly and monthly inspections of fire suppression systems were missing, unsecured helium and carbon dioxide tanks were found, elevator fire doors failed to self-close properly, and Emergency Action Plan training was not documented.

.155.01 Relocation agreements: the facility had two relocation agreements but they had not been updated annually; the last known review was in 2011.

.250.10.b Heating, ventilation, and air-conditioning (HVAC): the two-sided gas fireplace in the living/dining areas lacked safety barriers on both sides.

.405.01 Medical Gases: Electrical installations were not in accordance with NFPA 70; the marketing office used an outlet/junction box to supply power to a relocatable power tap with exposed wiring leaving from the conduit into the box.

.405.01.b Electrical Installations and Equipment: Multiple plug adapters and extension cords were prohibited but observed; the marketing office used a relocatable power tap plugged into a multiple plug adapter.

.405.05 Structure, Maintenance, Equipment to Assure Safety: Emergency light testing records were missing for June and annual testing; fire dampers lacked four-year testing records; missing and damaged ceiling tiles allowed smoke and fire to bypass protections in the kitchen and breakroom areas.

.405.05.f Structure, Maintenance, Equipment to Assure Safety: Portable heaters, which are prohibited, were used in Room N128 and Room N203, both plugged into relocatable power taps.

.410.02 Fire Drills: Fire drills were not documented for all shifts in the fourth quarter of 2019; evening or night shifts were missing for the third quarter of 2019; and day shifts were missing for the second quarter of 2019.

.415.05 Automatic Fire Extinguishing System Service and Testing: Only one of two semi-annual hood cleaning/inspections was completed in the past 12 months; no record of a 10-year dry system inspection was found, including UL testing or replacement of dry system pendants.

.250.01 Building Character: conduit at all mechanical and electrical rooms were not sealed, a closet in the dining area had a 6" x 12" hole in the ceiling, and a 4" x 4" junction box was missing a cover.

.250.13.l Resident Sleeping Rooms: resident room #220 closet doors had been removed without a variance.

.405.01.b Electrical Installations and Equipment: multiple extension cords and multi-plug adapters were used improperly in various rooms, creating daisy chains and unsafe electrical setups.

.405.03 Medical Gases: unsecured oxygen tanks were found in resident rooms #114 and #214.

.405.05.f Structure, Maintenance, Equipment to Assure Safety: an electric fireplace, which is a portable space heating device, was present in resident room #124.

.415.05 Automatic Fire Extinguishing System Service and Testing: missing documentation for a 4th quarter 2017 sprinkler inspection and kitchen hood cleaning last known in August 2017.

.410.02 Fire Drills: missing fire drill documentation for 3rd shift, third quarter 2017 and 2nd and 3rd shifts, fourth quarter 2017.

.305.02.b. Current Medication Orders and Treatment Orders: Resident #1's physician orders documented she was prescribed to take Potassium and Furosemide daily but she was taking the medications three times a week; Resident #2's physician ordered Lasix documented she was prescribed 40 mg every other day but she was taking 20 mg daily; Resident #5's renal diet order was not implemented.

.305.02.c. Current Medication Orders and Treatment Orders: Resident #3 did not have a written order for his continuous Oxygen use; Resident #2 did not have written orders for multiple medications including B50 Complex, Oregano Oil, N-Acetyl-L-Cysteine and an antibiotic.

.320.01. Use of Negotiated Service Agreement: NSA's did not reflect residents needs such as the level and frequency of assistance for eating, mobility including transferring, dressing, and bathing for Residents #1 through #7; Resident #5's NSA did not include special needs related to her dialysis or her diabetes management.

.730.01.e. Personnel: Four of seven employee records reviewed did not contain documentation of infection control training.

.152.05.b.iii. Policies of Acceptable Admissions: two residents had side rails attached to their beds (previously cited 7/9/2015).

.225.01. Evaluation for Behavior Management: behaviors of Residents #2, #4, #6, #7, and #10 were not evaluated (previously cited 7/9/2015).

.225.02. Intervention: the facility did not develop interventions to address Resident #10's behaviors.

.305.02.b. Current Medication Orders and Treatment Orders: residents did not receive medications as ordered, including Resident #1 not receiving correct insulin dose, Resident #3 missing low-dose Aspirin for several days, and Residents #5 and a Random Resident lacking portable oxygen during meals.

.305.03. Resident Health Status: the facility nurse did not document assessment of Resident #6's fall and Resident #10's complaints of dizziness (previously cited 8/12/2011 and 7/9/2015).

.310.04.e. Psychotropic or Behavior Modifying Medication: psychotropic medication reviews did not include behavioral updates to the physician (previously cited 8/12/2011 and 7/9/2015).

.320.01. Use of Negotiated Service Agreement: NSAs did not clearly describe residents' care needs (previously cited 7/9/2015).

.320.08. Requirements For The Negotiated Service Agreement. Periodic Review: NSAs were not updated to reflect significant changes in residents' health status, including Resident #1's and #5's wounds and preventative measures (previously cited 8/12/2011 and 7/9/2015).

.350.02. Administrator or Designee Investigation Within Thirty Days: the administrator did not document an investigation of all incidents and complaints (previously cited 7/9/2015).

.350.04. Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to all complaints (previously cited 7/9/2015).

.350.07. Notification of Licensing and Survey Agency Within Twenty-Four Hours: falls with injuries requiring treatment were not reported to Licensing and Certification (previously cited 7/9/2015).

.600.06.a. Sufficient Personnel: approximately 50 residents resided on two levels with only one caregiver scheduled for the night shift (previously cited 7/9/2015).

.630.04. Traumatic Brain Injury: two staff did not have evidence of traumatic brain injury training (previously cited 7/9/2015).

.711.01. Ongoing Resident Care Records: the facility did not track residents' behaviors.

.711.08. Care Notes: care notes were not written by the person providing the care and services.

.711.11. Medications Not Taken: there was no documentation describing why residents' medications were not given.

.725.01. Admission and Discharge Register: the admission and discharge register was not current.