Inspection Reports for Fir Lane Health & Rehabilitation Center

The inspection was conducted due to complaints regarding failure to notify resident representatives of multiple falls, inaccurate documentation and reconciliation of controlled substances, and failure to perform hand hygiene during medication administration.

The facility failed to notify the resident's representative of multiple falls for one resident, failed to accurately document and reconcile controlled substances for two residents, and failed to perform proper hand hygiene during medication administration by staff. These failures placed residents at risk for delayed medical treatment, medication misappropriation, and spread of infection.

The complaint investigation found substantiated issues including failure to notify family of falls, medication documentation errors indicating possible diversion, and inadequate infection control practices.

The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report allegations of abuse involving Resident 3.

The facility failed to report allegations of abuse to the State Agency within 24 hours for Resident 3, resulting in a delay of 3 days in reporting. This failure placed residents at risk of incidents not being reported and at risk for abuse and neglect.

The complaint investigation found that the facility did not report an allegation of abuse involving Resident 3 to the State Agency within the required 24 hours, instead reporting it 3 days later. Staff B, Director of Nursing Services, acknowledged the failure and stated it did not meet expectations.

The inspection was conducted based on complaints and allegations regarding resident rights, medication consent, advance directives, grievances, psychotropic medication use, abuse reporting, hospitalization notifications, PASARR screening, care planning, medication administration, infection control, food safety, arbitration agreements, and other regulatory compliance issues at Fir Lane Care.

The facility was found deficient in multiple areas including failure to honor resident rights related to medical appointments, failure to obtain consent before administering psychotropic medications, failure to inform residents about advance directives, inadequate grievance handling, failure to monitor psychotropic medications properly, delayed abuse reporting, failure to notify ombudsman of hospitalizations, incomplete PASARR screenings, incomplete care plans, medication administration errors, infection control lapses, food safety violations, and failure to properly explain binding arbitration agreements.

The visit was complaint-related, triggered by multiple allegations including failure to honor resident rights, medication consent issues, advance directive information, grievance handling, psychotropic medication monitoring, abuse reporting delays, ombudsman notification failures, PASARR screening inaccuracies, incomplete care plans, medication administration errors, infection control lapses, food safety violations, and arbitration agreement misunderstandings.

The inspection was conducted to assess the facility's compliance with care plan implementation and quality of care standards, focusing on Resident 1's care plan and overall resident care.

The facility failed to implement the care plan for Resident 1, who had a stage III pressure ulcer and required extensive assistance. Observations showed the resident was left in uncomfortable positions, was not assisted out of bed or to eat properly, and staff did not follow the care plan, placing the resident at risk for clinical complications and diminished quality of life.

The inspection was conducted due to complaints regarding failure to provide assistance with activities of daily living, medication administration errors, and infection control practices.

The facility failed to provide adequate assistance with bathing, dressing, and personal hygiene for residents, failed to ensure seizure medications were administered per physician orders resulting in actual harm to a resident, and failed to ensure staff used personal protective equipment properly when caring for residents with COVID-19, placing residents and staff at risk.

The complaint investigation found substantiated failures in care assistance, medication administration, and infection control practices, including failure to notify physician of medication refusals and unavailability.

The inspection was conducted to assess compliance with regulations regarding the use of physical restraints on residents in the facility.

The facility failed to ensure that residents were free from physical restraints unless medically necessary, affecting 3 of 3 residents observed. Residents were restrained with Velcro straps or tilted wheelchairs beyond recommended angles, restricting their freedom of movement without proper physician orders or care plans.

The inspection was conducted to assess compliance with care plan implementation, wound care, and overall quality of care at Fir Lane Care nursing home.

The facility failed to implement care plan interventions for two residents, resulting in risks for poor hygiene and clinical complications. Additionally, the facility failed to accurately assess and timely intervene in pressure ulcer care for one resident, leading to actual harm including hospitalization and amputation.

The inspection was conducted following a complaint and notification of an Immediate Jeopardy (IJ) due to a resident sustaining a significant second degree burn from being found unsupervised seated on a baseboard heater in the locked dementia unit.

The facility failed to ensure a safe environment free from hazards for 17 residents in the locked dementia unit, resulting in a resident sustaining a large second degree burn from a baseboard heater. The facility had issues with heater temperature regulation and equipment malfunction, which placed residents at risk of serious injury. The facility removed the immediacy by repairing heaters, staff education, and temperature monitoring.

The visit was complaint-related due to a resident sustaining burns after being found unsupervised against a baseboard heater. The facility was notified of an Immediate Jeopardy on 12/10/2024 and removed the immediacy on 12/13/2024 after corrective actions.

The inspection was conducted due to a complaint investigation regarding the facility's failure to follow its policy to prevent resident elopement, specifically concerning Resident 4 who left the facility unattended.

The facility failed to follow its elopement prevention policy for Resident 4, who eloped multiple times without proper documentation, care planning, or physician orders for monitoring devices. The wander guard alarm was not functioning properly, and the resident's care plan did not indicate elopement risk. Staff acknowledged these failures and that the facility did not follow its policy.

The complaint investigation found that Resident 4 eloped from the facility on multiple occasions, including on 08/13/2024 and 08/26/2024, with no documentation or care plan indicating elopement risk. Staff acknowledged the lack of physician's order for the wander guard and that the alarm was not functioning properly. Resident 4 left against medical advice on 08/26/2024.

The inspection was conducted due to a complaint regarding the facility's failure to assess and treat pain for a resident who required pain management services.

The facility failed to provide appropriate pain management for one resident, resulting in untreated pain and diminished quality of life. Staff did not administer prescribed pain medication on the day of admission due to lack of medication orders and access issues with the medication dispensing system.

The complaint investigation found that Resident 1 was admitted with a broken leg requiring surgery but did not receive pain medication on 07/24/2024 due to staff not having orders and lack of access to the medication dispenser. Staff acknowledged the failure to assess and treat pain on that date.

The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely notification of an emergency transfer to the resident, their representative, and the Office of the State Long-Term Care Ombudsman, and failure to permit a resident to return to the nursing home after hospitalization.

The facility failed to provide written notification of an emergency transfer to the resident and relevant parties, placing residents at risk of uninformed decisions and lack of advocacy. Additionally, the facility failed to consider re-admission of a resident after an unplanned hospitalization, resulting in increased anxiety and diminished quality of life for the resident.

The complaint investigation found that the facility did not provide required written notification of an emergency transfer to the resident, their representative, or the Office of the State Long-Term Care Ombudsman. The facility also failed to consider re-admission of a resident after hospitalization, did not provide notice of inability to provide care, and lacked documentation of discharge planning or communication with the resident.

The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, personal funds management, grievance policies, PASARR coordination, baseline care planning, medication administration, vision and hearing services, nutrition and dietary services, respiratory care, staffing adequacy, social services, and food safety.

The facility was found deficient in multiple areas including failure to honor resident bathing and room preferences, failure to provide quarterly personal fund statements, failure to notify residents about personal fund balances affecting Medicaid eligibility, failure to initiate resident grievances, failure to follow PASARR recommendations, failure to develop baseline care plans within 48 hours, medication administration errors, failure to provide vision services timely, inaccurate fluid intake documentation, oxygen therapy without orders, insufficient nursing staff, failure to provide medically related social services, failure to monitor refrigerator temperatures, food quality and safety issues, failure to accommodate resident food preferences and allergies, and failure to provide prescribed therapeutic diets.

The inspection was conducted to assess compliance with RN staffing requirements, specifically to verify if the facility provided eight consecutive hours of direct care supervision by a Registered Nurse and 24-hour RN coverage as required by state regulations.

The facility failed to provide eight consecutive hours of direct care supervision by an RN for 2 of 32 days reviewed and did not meet the state requirement of 24-hour RN coverage for all 32 days reviewed. This placed residents at risk for delayed assessments, identification of condition changes, and unmet care needs.

The inspection was conducted to investigate a complaint regarding the facility's failure to include the resident's designated legal representative in decisions related to the resident's health needs, specifically concerning transfer and discharge.

The facility failed to ensure that the resident's designated legal representatives were involved in discharge planning and decision-making, resulting in an unplanned and unsafe discharge to the emergency room without proper communication or documentation. Staff were unsure if the family members present were the legal representatives, and there was no coordination with the receiving facility.

The complaint investigation found that the facility did not include the resident's designated legal representatives in decisions about transfer and discharge, leading to an unsafe and unplanned discharge. Staff interviews revealed uncertainty about the identity of the family members involved and lack of communication with the receiving facility. The resident was discharged to the emergency room without documented discharge planning or resident involvement.

The inspection was conducted due to a complaint investigation regarding the facility's failure to investigate a potential misappropriation of property involving Resident 75.

The facility failed to ensure that the alleged misappropriation of property was investigated for one of three sampled residents, placing residents at risk for abuse, misappropriation of property, and diminished quality of life. Staff reported the incident verbally but did not document or investigate it as required by facility policy.

The complaint investigation found that the facility did not document or investigate an alleged misappropriation of property reported by Staff C to Adult Protective Services on 05/09/2023. Staff B and Staff A acknowledged lack of documentation and investigation despite verbal reports.

The inspection was conducted based on complaints and allegations related to resident rights, medication consent, accommodation of needs, advance directives, privacy and confidentiality, homelike environment, abuse investigation, medication administration, respiratory care, RN coverage, unnecessary medications, and vaccination procedures.

The facility was found deficient in multiple areas including failure to respect resident dignity and privacy, failure to obtain consent for psychotropic medication, inadequate accommodation of resident needs such as call light accessibility, failure to maintain advance directives documentation, failure to maintain confidentiality of medical records, failure to provide a homelike environment, failure to investigate alleged misappropriation of property, failure to complete accurate PASARR assessments, failure to implement physician orders for medications and bowel management, failure to maintain proper feeding tube care, failure to follow oxygen orders, inadequate RN coverage, failure to monitor unnecessary medications including psychotropics, failure to label and store medications properly, and failure to offer influenza and pneumococcal vaccinations.

The visit was complaint-related, triggered by multiple allegations including failure to respect resident rights, medication consent issues, accommodation failures, missing advance directives, privacy breaches, inadequate investigation of abuse allegations, medication administration errors, respiratory care deficiencies, insufficient RN coverage, unnecessary medication use, improper medication labeling and storage, and failure to offer vaccinations.

The inspection was conducted following allegations of inappropriate touching between residents and concerns about resident safety related to a burn injury from hot coffee and inadequate supervision to prevent accidents and resident-to-resident altercations.

The facility failed to ensure care plan updates were completed for one resident, failed to prevent a significant burn injury from hot coffee to a resident, and failed to supervise resident interactions adequately to prevent inappropriate touching and altercations between two residents. These failures placed residents at risk of harm and diminished quality of life.

The complaint involved allegations of inappropriate touching of Resident 1 by Resident 2, which were investigated but not substantiated. Observations during the survey confirmed inappropriate touching behaviors and inadequate supervision. The facility investigations documented incidents on 01/18/2023 and 03/30/2023, with monitoring and interventions lacking. Resident 2 was placed on one-to-one monitoring but care plans did not adequately address behaviors. The facility was unable to substantiate the allegations but continued monitoring for psychosocial harm.

The inspection was conducted to investigate complaints regarding failure to provide adequate activities of daily living (ADLs), range of motion (ROM) care, hydration, and feeding tube management for residents.

The facility failed to provide consistent bathing assistance, appropriate restorative care for limited range of motion, adequate hydration monitoring and administration, and proper enteral nutrition and fluid management according to physician orders. These failures placed residents at risk for poor hygiene, contractures, dehydration, medical complications, and diminished quality of life.

The visit was complaint-related, triggered by allegations of inadequate care in bathing, range of motion, hydration, and feeding tube management. Substantiation status is not explicitly stated.