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Deficiency Records for Fir Lane Care
A list of the most recent deficiencies for Fir Lane Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Fir Lane Care. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-06 | 2024-07-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-06 | 2024-07-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-24 | 2024-06-26 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-05-24 | 2024-06-26 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-05-10 | 2024-06-14 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-05-10 | 2024-06-14 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-05-10 | 2024-06-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-05-10 | 2024-06-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-10 | 2024-06-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-10 | 2024-06-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-10 | 2024-06-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-05-10 | 2024-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-10 | 2024-06-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-10 | 2024-06-14 | 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 | 2024-05-10 | 2024-06-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-05-10 | 2024-06-14 | 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 | 2024-05-10 | 2024-06-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-10 | 2024-06-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-05-10 | 2024-06-14 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-05-10 | 2024-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-10 | 2024-06-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-05-06 | 2024-06-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-05-06 | 2024-06-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-06 | 2024-06-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-06 | 2024-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-06 | 2024-06-05 | 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 | 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 |
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