Fairwood Northridge LLC

The facility failed to notify the prescribing health care provider of medication refusals for 1 resident (Resident 9), who had 267 recorded refusals over three months.

The facility failed to obtain medications in a timely manner for 2 residents (Residents 2 and 11), leading to missed doses.

The facility failed to conduct a Character, Competence and Suitability (CC&S) review for one staff member (Staff B) who had a nondisqualifying background check result.

Facility failed to ensure water temperatures were maintained between 105-120 degrees Fahrenheit for 5 of 6 common area sinks and 3 of 5 sampled resident rooms, resulting in a resident getting scalded.

The facility failed to ensure a safe medication delivery system for 2 residents (Residents 3 and 4), resulting in medications not being administered as prescribed.

The facility failed to delegate nursing tasks for medication administration and failed to complete 90-day nursing assessments for 4 of 9 sampled residents (Residents 1, 5, 6, and 7).

The facility failed to ensure home-care aide certification for 5 of 11 sampled staff (Staff A, C, F, G, and K) who were actively providing personal care to residents.

The facility failed to complete annual facility assessments for 3 of 9 sampled residents (Residents 2, 3, and 7), leading to delayed assessments ranging from 5 weeks to over 5 months late.

Facility failed to ensure TB screenings were conducted within three days of employment for 2 of 3 staff (Staff A and C).

The facility failed to protect resident health information on 3 of 4 medication carts; staff left laptops unlocked/unattended with patient information visible and posted a list of residents with appointments in a public area.

Facility failed to ensure a written plan for family assistance with medication was in place for 2 of 10 sampled residents (Resident 1 and 8).

Negotiated service agreement did not identify who had access to video recording footage and facility did not obtain signed consent each quarter.

Facility did not have policies for medication refusals, non-availability of medications, and nurse delegation.

Electrical panels in staff areas were not locked.

Facility unable to provide documentation for semi-annual hood cleaning.

Wall penetration found in memory care wall between Mechanical/Janitor's closet.

Multiple sprinkler escutcheons missing or loose; documentation missing for annual, 5-year internal, 3-year dry system, and quarterly inspections.

Kitchen fire extinguisher has not had annual maintenance.

Facility unable to provide documentation for monthly emergency light activation tests (Aug-Nov 2025).

Oxygen cylinders unsecured in Room 26 and Room 30.

Heater was plugged into a powerstrip in the lower level nurses office.

Unapproved extension cord in use in room 37.

Facility unable to provide documentation of annual fire wall inspection.

Lower level fire door by med room blocked open by a wheelchair.

Facility unable to provide documentation for semi-annual kitchen suppression system servicing.

Facility unable to provide documentation for annual fire alarm system testing and maintenance.

Facility unable to provide documentation for monthly CO detector maintenance (Aug-Nov 2025).

Facility unable to provide documentation for annual 90-minute power test.

Facility has not completed fire drills since March 2025.

Facility failed to ensure 2 of 5 sampled staff met annual continuing education requirements.

Failed to complete full assessments within 14 days of move-in for 3 of 9 sampled residents.

Facility failed to ensure agreed-upon podiatry services (toenail trimming) were provided for Resident 4, resulting in pain and discomfort.

The facility failed to complete a final Negotiated Service Agreement (NSA) within 30 days of move-in for residents. Staff confirmed they did not complete a final NSA within this timeframe.

Failed to evaluate caregiver competency upon initiation of delegated tasks, failed to perform 90-day assessments for residents/staff, and failed to verify nine-hour core delegation training for staff.

Negotiated service agreements were not signed by the resident or their representative for 6 of 9 sampled residents.

Failed to complete a negotiated service agreement within 30 days of move-in for 2 of 9 sampled residents.

Facility administrator did not have a designee available, and staff were unaware of the process to contact the administrator when they were not on the premises.

Staff observed wearing respirator masks improperly, improper removal of PPE when exiting isolation, improper handling of isolation waste, and staff respirator fit testing had expired.

Staff observed wearing respirators improperly, removing PPE incorrectly upon exiting isolation, handling waste without gloves, and using expired fit testing. Isolation waste bin had waste protruding.

Facility did not have a designee available in the administrator's absence; staff were unaware of a process to contact the administrator.