A list of the most recent deficiencies for Fir Lane Health and Rehab Ctr. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-22 | 2024-02-08 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-08-25 | 2023-09-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-08 | 2023-07-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-07-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-09 | 2023-07-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-09 | 2023-07-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-09 | 2023-07-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-09 | 2023-07-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-09 | 2023-07-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-09 | 2023-07-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-09 | 2023-07-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-09 | 2023-07-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-06-09 | 2023-07-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-09 | 2023-07-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-09 | 2023-07-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-09 | 2023-07-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-09 | 2023-07-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-09 | 2023-07-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-09 | 2023-07-10 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-09 | 2023-07-10 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-07 | 2023-07-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-07 | 2023-07-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-07 | 2023-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-07-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-07 | 2023-07-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-07 | 2023-07-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-07 | 2023-07-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-28 | 2023-05-29 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-28 | 2023-05-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-28 | 2023-05-29 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-04-28 | 2023-05-29 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-12-21 | 2023-01-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-21 | 2023-01-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-21 | 2023-01-16 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-21 | 2023-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-07 | 2022-11-01 | Y |
| Install proper backup exit lighting. | Fire Safety | 2022-08-19 | 2022-10-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-08-19 | 2022-10-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-19 | 2022-10-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-19 | 2022-10-22 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-08-19 | 2022-10-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-19 | 2022-09-23 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2022-08-19 | 2022-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-19 | 2022-09-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-19 | 2022-09-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-19 | 2022-09-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-19 | 2022-09-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-17 | 2022-09-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-17 | 2022-09-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-17 | 2022-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-17 | 2022-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-17 | 2022-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-17 | 2022-09-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-02-23 | 2022-03-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-23 | 2022-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-23 | 2022-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-23 | 2022-03-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-07 | 2022-02-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-07 | 2022-02-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-07 | 2022-02-08 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-01-07 | 2022-02-08 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-01-07 | 2022-02-08 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-01-07 | 2022-02-08 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-01-07 | 2022-02-08 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-01-07 | 2022-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-02-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-07 | 2022-02-08 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-01-07 | 2022-02-08 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-09-23 | 2021-10-22 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-23 | 2021-10-22 | Y |
| Provide appropriate foot care. | Health | 2021-09-23 | 2021-10-22 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-09-23 | 2021-10-22 | Y |
| Report COVID19 data to residents and families. | Health | 2021-09-01 | 2021-09-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-09 | 2021-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-09 | 2021-09-07 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-08-09 | 2021-09-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-21 | 2020-02-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-01-21 | 2020-02-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-21 | 2020-02-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-21 | 2020-02-29 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-21 | 2020-02-29 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-21 | 2020-02-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-01-21 | 2020-02-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-21 | 2020-02-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-21 | 2020-02-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-21 | 2020-02-29 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-01-21 | 2020-02-29 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2020-01-21 | 2020-02-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-21 | 2020-02-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-21 | 2020-02-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-21 | 2020-02-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-21 | 2020-02-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-21 | 2020-02-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-01-21 | 2020-02-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-21 | 2020-02-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-01-06 | 2020-02-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-06 | 2020-02-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-06 | 2020-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-06 | 2020-02-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-01-06 | 2020-02-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-06 | 2020-02-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-06 | 2020-02-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-06 | 2020-02-10 | N |