Fairlawn Health and Rehabilitation of Cascadia

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure food was labeled and stored in a manner to avoid spoilage in 2 of 2 kitchens and failed to properly follow dish sanitizing practices and sanitization of food preparation surfaces for 1 of 2 kitchens. This placed residents at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control precautions for 2 of 3 sampled hallways (north hall and west hall) reviewed for infection control. This placed the residents at risk of acquiring an infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident meals were served at an appetizing temperature in hallways for 1 of 1 facility reviewed for food. This placed residents at risk for inadequate nutritional intake.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 2 resident rooms (room [ROOM NUMBER]) reviewed for environment. This placed residents at risk for a lessened quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 2 sampled residents (#210) reviewed for safe discharges. This placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure safety interventions for fall prevention were followed for 1 of 4 residents (#26) reviewed for accidents. This placed residents at risk for accidents.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow catheter care orders for 1 of 1 resident (# 53) reviewed for catheter care. This placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 3 sampled residents (#1) reviewed for discharge. This placed residents at risk for unmet discharge needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 3 and 4) reviewed for bowel care. This placed other residents at risk for bowel complications.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for medication administration for 1 of 3 residents (# 501) reviewed for medication administration timeliness. This placed residents at risk for reduced medication efficacy and adverse medication side effects.

Inspectors wroteBased on interview and record review it was determined the facility failed to administer Warfin (blood thinner) as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#1) reviewed for medication administration. The placed the resident at risk for adverse side effects of medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 8 sampled residents (#107) reviewed for medications. As a result, Resident 107 received a diabetic medication, she/he did not have a diabetic condition, and experienced seizure activity due to severe hypoglycemia (low blood sugar) with a blood sugar level of 19 upon arrival at the hospital. Resident 107's blood sugar levels did not stabilize and she/he became unresponsive and was transferred to the hospital.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to appropriately prepare, distribute, serve and store kitchen cookware for 2 of 2 kitchens reviewed for food services quality. This placed residents at risk for contaminated food.

Inspectors wroteBased on observation and interview it was determined the facility failed to inform residents of the location of 1 of 1 State survey inspection results and failed to ensure the survey results were readily accessible. This placed residents and public at risk for lack of knowledge regarding quality of care and quality of life concerns within the facility.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 107 out of 107 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure meals were palatable, attractive and served at an appropriate temperature for 2 of 3 halls and 2 of 2 sampled residents (#s 45 and 55) reviewed for food quality. This placed residents at risk for unmet needs.

Inspectors wroteBased on record review and interview it was determined the facility failed follow up on advance directives for 1 of 5 sampled residents (#20) reviewed for advanced directives. This placed residents at risk for choices not being honored.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's representative was notified of a new medication and treatment order for 1 of 8 sampled residents (#107) reviewed for medications. This placed residents at risk for being administered medication and treatments for a condition the resident did not have.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to comprehensively assess the use of an urinary catheter for 1 of 1 sampled resident (#6) reviewed for catheters. This placed residents at risk for unassessed needs.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to develop a resident centered care plan for 3 of 6 sampled residents (#'s 3, 17 and 56) reviewed for activities, communication and nutrition. This placed resident at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being for 1 of 2 sampled residents (#17) reviewed for activities. Failure to provide meaningful and regular activities placed residents at risk for unmet psychosocial needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to keep a medication needle attended and out of residents' access for 1 of 5 sampled residents (#19) reviewed for accidents. This placed residents at increased risk for injury.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to determine if a resident's clinical condition necessitated catheterization for 1 of 1 sampled resident (#6) reviewed for urinary catheters. This placed residents at risk of unnecessary urinary catheterization.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure a resident was free from receiving incorrect medication for 1 of 7 sampled residents (#208) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications and side effects.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adequate care and services related to catheter care for 1 of 1 sampled resident (#6) reviewed for urinary catheter care. This placed residents at risk for infection and displacement of the catheter.