Deficiency Records for Fir Lane Health and Rehab Ctr
Updated as of August 01, 2022
This is not the most recent data for Fir Lane Health and Rehab Ctr. For the most recent information, click here.
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? |
---|---|---|---|---|
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 |
Perform COVID19 testing on residents and staff. | 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 |
Provide and implement an infection prevention and control program. | Health | 2020-11-13 | 2021-02-01 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-01-06 | 2021-02-01 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-11-18 | 2021-02-01 | Y |
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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-21 | 2020-02-29 | Y |
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 | Y |
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 | Y |
Respond appropriately to all alleged violations. | Health | 2020-01-21 | 2020-02-29 | Y |
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 | Y |
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 | Y |
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 | Y |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-21 | 2020-02-29 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-21 | 2020-02-29 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-21 | 2020-02-29 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-21 | 2020-02-29 | Y |
Assist a resident in gaining access to vision and hearing services. | Health | 2020-01-21 | 2020-02-29 | 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 | 2020-01-21 | 2020-02-29 | Y |
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 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-21 | 2020-02-29 | 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 | 2020-01-21 | 2020-02-29 | Y |
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 | Y |
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 | Y |
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 | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-21 | 2020-02-29 | Y |
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 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-01-21 | 2020-02-29 | Y |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-21 | 2020-02-29 | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-01-21 | 2020-02-29 | Y |
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 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-28 | 2020-02-29 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-02-05 | 2020-02-29 | Y |
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2020-02-05 | 2020-02-29 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-05 | 2020-02-29 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-02-05 | 2020-02-29 | Y |
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 |
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-02-28 | 2019-04-16 | 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 | 2019-02-28 | 2019-04-16 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-28 | 2019-04-16 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-28 | 2019-04-16 | 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 | 2019-02-28 | 2019-04-16 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-28 | 2019-04-16 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-28 | 2019-04-16 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-28 | 2019-04-16 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-28 | 2019-04-16 | 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 | 2019-02-28 | 2019-04-16 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-28 | 2019-04-16 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-28 | 2019-04-16 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-02-28 | 2019-04-16 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-28 | 2019-04-16 | 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 | 2019-02-28 | 2019-04-16 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-28 | 2019-04-16 | 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 | 2019-02-28 | 2019-04-16 | N |
Provide or obtain dental services for each resident. | Health | 2019-02-28 | 2019-04-16 | N |
Provide and implement an infection prevention and control program. | Health | 2019-02-28 | 2019-04-16 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-02-28 | 2019-04-16 | N |
Keep all essential equipment working safely. | Health | 2019-02-28 | 2019-04-16 | N |
Conduct testing and exercise requirements. | Fire Safety | 2019-02-20 | 2019-03-26 | N |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-02-20 | 2019-03-26 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-20 | 2019-03-26 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-20 | 2019-03-26 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-20 | 2019-03-26 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-20 | 2019-03-26 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-20 | 2019-03-26 | 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 | 2018-04-11 | 2018-05-22 | 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 | 2018-04-11 | 2018-05-22 | N |
Respond appropriately to all alleged violations. | Health | 2018-04-11 | 2018-05-22 | 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 | 2018-04-11 | 2018-05-22 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-04-11 | 2018-05-22 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-11 | 2018-05-22 | N |
Provide activities to meet all resident's needs. | Health | 2018-04-11 | 2018-05-22 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-11 | 2018-05-22 | 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 | 2018-04-11 | 2018-05-22 | 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 | 2018-04-11 | 2018-05-22 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-11 | 2018-05-22 | 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 | 2018-04-11 | 2018-05-22 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-11 | 2018-05-22 | 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 | 2018-04-11 | 2018-05-22 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-11 | 2018-05-22 | N |
Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2018-04-11 | 2018-05-22 | N |
Provide and implement an infection prevention and control program. | Health | 2018-04-11 | 2018-05-22 | N |
Keep all essential equipment working safely. | Health | 2018-04-11 | 2018-05-22 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-09 | 2018-05-02 | N |