Inspection Reports for
Fir Lane Health & Rehabilitation Center

The investigation involved three main allegations: failure to notify a resident's representative of multiple falls, failure to properly document and reconcile controlled substances, and failure to perform hand hygiene during medication administration. The allegations were substantiated with citations issued for each.

The facility was found to have failed in notifying a resident's representative of multiple falls, improperly documenting and reconciling controlled substances for two residents, and failing to perform hand hygiene during medication administration by staff. These failures placed residents at risk for delayed care, medication misappropriation, and infection spread. All findings were cited with minimal harm and affected few residents.

The facility was found deficient in multiple areas including failure to honor resident rights, incomplete consent for psychotropic medications, inadequate grievance handling, insufficient monitoring of psychotropic medications, delayed abuse reporting, failure to notify ombudsman of hospitalizations, inaccurate PASARR screenings, incomplete care plans, medication administration errors, inadequate wound and catheter care, poor nutritional and fluid intake monitoring, insufficient restorative nursing services, improper medication storage and labeling, incomplete arbitration agreement explanations, and lapses in infection control practices. Many deficiencies were noted as minimal harm but placed residents at risk for diminished quality of life.

The complaint involved a failure to timely report suspected abuse for Resident 3. The allegation was substantiated as the report was delayed beyond the required timeframe.

The facility failed to report allegations of abuse to the State Agency within the required 24-hour timeframe for one resident. The delay placed residents at risk of unreported incidents and potential abuse.

The complaint investigation focused on Resident 1's care plan implementation. Observations and staff interviews confirmed the resident was not repositioned or assisted as required. The deficiency was substantiated with minimal harm and few residents affected.

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 an uncomfortable position in bed, unable to eat properly, and was not assisted out of bed as required by the care plan. Staff acknowledged the failure to follow the care plan, and the deficiency was cited with minimal harm and few residents affected.

The investigation was complaint-driven, focusing on allegations of inadequate personal care, medication administration errors, and infection control failures. The allegations were substantiated as deficiencies were cited affecting multiple residents and staff practices.

The facility failed to provide adequate assistance with bathing, dressing, and personal hygiene for some residents, failed to administer seizure medications 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. Several residents were affected, and some deficiencies caused actual harm.

The complaint investigation found that Residents 1, 2, and 3 were physically restrained without proper documentation or physician orders. Resident 1 had a Velcro strap securing their arm without assessment or consent. Residents 2 and 3 were placed in tilt in space wheelchairs tilted back to 45 degrees, restricting their freedom of movement beyond the 20-degree limit prescribed by the Director of Nursing. The facility staff were unaware or did not document these restraints properly.

The facility failed to ensure three residents were free from physical restraints when medical devices restricted their freedom of movement. The use of Velcro straps and tilt in space wheelchairs were not properly authorized or documented, placing residents at risk of injury and decreased quality of life. The facility staff were found to be restricting residents' freedom of movement beyond approved limits.

The complaint investigation found substantiated failures in care plan implementation for Residents 2 and 3, and wound care deficiencies for Resident 1 that caused actual harm. The facility did not consistently implement care plans or communicate wound status effectively.

The facility failed to implement care plan interventions for two residents, resulting in risks of poor hygiene and clinical complications. Additionally, the facility failed to prevent and properly manage pressure ulcers for one resident, leading to actual harm including hospitalization and amputation. Documentation and communication deficiencies were noted.

The facility failed to ensure a safe environment free from hazards for 17 residents in the dementia unit, resulting in a resident sustaining a serious burn injury. The Immediate Jeopardy was removed after the facility implemented temperature monitoring, staff education, and heater repairs.

The complaint investigation focused on Resident 4's multiple elopements on 08/13/2024, 08/15/2024, and 08/26/2024. The facility acknowledged failures including no physician's order for the wander guard, no care plan indication of elopement risk, and lack of documentation. Staff interviews confirmed these issues and the malfunctioning wander guard alarm.

The facility failed to follow its elopement prevention policy for Resident 4, who eloped multiple times without proper documentation, physician orders, or care plan indications. The wander guard alarm was applied without a physician's order and was not functioning properly, placing residents at risk of elopement and accidents.

The complaint involved failure to assess and treat pain for Resident 1. The investigation found that Resident 1 did not receive prescribed pain medication on 07/24/2024 due to staff not having medication orders and lack of access to the medication dispenser. The complaint was substantiated as the facility acknowledged the failure.

The facility failed to provide timely pain management for one resident, resulting in untreated pain overnight due to lack of medication orders and staff access issues. The Director of Nursing acknowledged the failure to assess and treat the resident's pain on the day of admission.

The complaint investigation focused on two main issues: failure to provide timely notification of an emergency transfer for Resident 1, and failure to permit Resident 1 to return to the facility after hospitalization. The investigation found both allegations substantiated, with documented failures in notification and discharge planning.

The facility failed to provide required written notification of an emergency transfer to the resident, their representative, and the Office of the State Long-Term Care Ombudsman. Additionally, the facility failed to consider re-admission of a resident after an unplanned hospitalization and did not provide formal notice or documentation regarding the inability to provide care, placing the resident at risk and causing diminished quality of life.

The investigation included multiple resident interviews, staff interviews, record reviews, and observations revealing failures in honoring resident preferences, personal fund management, grievance handling, PASARR follow-up, baseline care planning, medication administration, vision services, fluid intake monitoring, oxygen therapy, staffing adequacy, social services, medication storage, food quality and safety, dietary accommodations, and therapeutic diet provision.

The facility was found to have multiple deficiencies including failure to honor resident bathing and room preferences, inadequate personal fund statement provision, failure to notify residents of fund balances, failure to initiate grievances, failure to follow PASARR recommendations, delayed baseline care planning, medication order and administration errors, failure to provide timely vision services, inaccurate fluid intake documentation, oxygen therapy without orders, insufficient nursing staff, inadequate social services for mental health needs, missing refrigerator temperature logs, poor food quality and preparation, failure to accommodate resident allergies and preferences, and unsafe food storage practices.

The facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse for 2 of 32 days reviewed and did not meet the 24-hour RN coverage requirement for all 32 days reviewed. The facility was aware of these deficiencies and had applied for an RN staffing waiver.

The complaint investigation focused on Resident 1's discharge process and the involvement of the designated legal representatives. The investigation found that the discharge was unplanned and the POAs were not properly included or verified. Staff interviews confirmed lack of communication and documentation. The complaint was substantiated as deficiencies were cited.

The facility failed to ensure the resident's designated legal representatives were involved in discharge planning, resulting in an unplanned discharge to the emergency room without proper communication or documentation. The resident was discharged without confirmation that the receiving facility would meet the resident's needs, and the designated POAs were not verified or included in discussions.

The complaint involved an allegation of misappropriation of property for Resident 75. The facility did not document or investigate the incident as required. Staff verbally reported the incident to Adult Protective Services but lacked documentation. The complaint was substantiated by the deficiency citation.

The facility failed to ensure that the alleged misappropriation of property was properly investigated and documented for Resident 75. Staff reported the incident verbally and to Adult Protective Services but did not provide documentation as required by facility policy.

The facility was found to have multiple deficiencies including failure to respect resident privacy, lack of informed consent for psychotropic medication, inadequate call light accessibility, missing advance directives, failure to maintain confidentiality of medical records, unsafe and non-homelike environment, failure to investigate alleged misappropriation of property, inaccurate PASARR screening, medication administration errors, inadequate bowel management, improper feeding tube care, incorrect oxygen therapy administration, insufficient RN coverage, failure to monitor anticoagulant complications, lack of gradual dose reductions for psychotropic medications, improper medication labeling and storage, and failure to offer influenza and pneumococcal vaccinations. All deficiencies were cited with minimal harm or potential for harm.

The complaint involved allegations of inappropriate touching by Resident 2 towards Resident 1, with investigations on 01/18/2023 and 03/30/2023. The facility was unable to substantiate the allegations but noted ongoing monitoring needs. Additionally, a significant burn injury occurred due to hot coffee being served improperly. The complaint investigation found failures in care plan updates and supervision.

The facility failed to update care plans to address resident behaviors and failed to ensure a safe environment, resulting in a significant burn injury to one resident and inadequate supervision to prevent inappropriate resident interactions. Some allegations of inappropriate touching were unsubstantiated, but monitoring and care plan updates were lacking.

The investigation was complaint-driven, focusing on allegations of inadequate bathing, range of motion care, hydration, and feeding tube management. The findings substantiated these allegations with citations issued for failures in care.

The facility failed to provide adequate bathing assistance, restorative range of motion care, hydration monitoring, and proper feeding tube management for several residents. These failures placed residents at risk for poor hygiene, contractures, dehydration, medical complications, and diminished quality of life. The deficiencies were cited with minimal harm and affected a few residents.