Fir Lane Care

Inspectors wroteBased on interview and record review, the facility failed to ensure restorative services (assessed nursing interventions to promote a resident's ability to maintaining functional abilities and independence) were provided for 3 of 3 residents (Resident 10, 6 & 32) reviewed for restorative services. This failure placed residents at risk of physical decline, loss of ability to perform activities of daily living, and a diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to prevent cross contamination during meal preparation services for 1 of 1 kitchen, reviewed for food service safety. The failure to prevent cross contamination placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure binding arbitration agreements were explained in a manner that residents understood, for 3 of 3 residents (Resident 64, 27 & 78) reviewed for binding arbitration (an agreement to use a third-party mediator and waives the right to a trial by jury). This failure placed residents at risk of signing away their rights, not understanding what they had signed, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow gradual dose reduction (GDR) requirements and/or to monitor psychotropic medications (altering the mental state) for 3 of 5 residents (Resident 2, 56 & 32) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medications, side effects, and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 5 sampled residents (Residents 82, 2 & 56) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure weekly skin evaluations were completed accurately and wound care was documented on the Treatment Administration Record (TAR) for 1 of 1 sampled Resident (13) reviewed for pressure ulcer (PU). These failures placed the resident at risk of a delay in treatment, deterioration of the PU, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents requiring dialysis (procedure that filters out waste and excess fluid from the blood, helping to regulate blood pressure) were appropriately monitored and treated for blood pressure and fluid restrictions, and communication from dialysis was accurately recorded into their medical record for 1 of 1 resident (Resident 7) reviewed for dialysis. This failure placed residents at risk of medical complications including fluid overload, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications by failing to follow medication parameters, ensuring medications had a clear indication for use, re-evaluating necessity of scheduled opioid medication and/or addressing pharmacy recommendations for 3 of 5 sampled residents (Residents 56, 2 & 82) reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications and at risk of medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5 percent (%). During observation of 25 opportunities for error, 1 of 3 Licensed Nurses (Staff H) made 2 errors, an error rate of 8%. This failure placed residents at risk for adverse side effects related to not following parameters and not receiving the correct medication according to the physician orders.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accessible medical records of hospice nursing and hospice health aide visits for 1 of 1 Residents (Resident 3) reviewed for hospice. This failure placed residents at risk of not having a record of assessments and services provided and a decreased quality of care.

Inspectors wroteBased on interview and record review, the facility failed to provide the notice of transfer or discharge and the bed hold policy in writing for 2 of 3 residents (Resident 1 and 2) reviewed for discharge notice. This failure placed residents and/or representatives at risk for lack of advocacy for discharge rights, housing options, and frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a functional and/or sanitary environment for residents for 2 of 3 sampled residents (Residents 3 &4) reviewed for environment. This failure places residents at risk of discomfort, their environment being unhomelike and unsanitary, and of a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse from other residents in the facility for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of further abuse, injury, mental anguish and fear.

Inspectors wroteBased on interview and record review, the facility failed to communicate, develop and implement an effective discharge plan and provide sufficient time and orientation prior to discharge for 1 of 3 residents (Resident 1) reviewed for discharge. This failure placed residents at risk of displacement, adequate housing and a decreased quality of life. Resident 1 was admitted to the facility on [DATE] with diagnoses including ankle infection, mood disorder and substance abuse. Resident 1 was discharged from the facility on 02/19/2026. Resident 1's Minimum Data Set Assessment, dated 01/04/2026, showed Resident 1 was cognitively intact. Resident 1's Mobility Care Plan, dated 12/29/2025, showed Resident 1 had limited mobility r/t [related to] weight bearing restrictions NWB [non weight bearing RLE [right lower extremity] for 6 weeks. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Long-Term Care Ombudsman of a facility discharge for 1 of 3 (Resident 1) residents reviewed for discharge. This failure placed residents at risk of being inappropriately discharged and lack of advocacy regarding their options and rights.

Inspectors wroteBased on interview and record review, the facility failed to provide informed consent and communicate preferences for Cardiopulmonary Resuscitation (CPR) to the resident and/or representative for 1 of 3 residents (Resident 1) reviewed. This failure placed residents and/or residents' representatives at risk for not being fully informed of health care decisions and residents' health care advocates not available to assist them in decision making.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan interventions for low meal intake and diet modifications for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of malnutrition, clinical complications and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately and/or timely assess and monitor a pressure ulcer for 1 of 3 residents (Resident 1) reviewed for wounds. This failure placed residents at risk of worsening pressure ulcers, lack of treatment evaluation and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the clinical condition for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of inaccurate medical records, inaccurate assessments and lack of continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident Representative of multiple falls for 1 of 3 (Resident 3) residents reviewed. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, providing support, delayed medical treatment, and a diminished quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to accurately document and reconcile controlled substances for 2 of 3 (Resident 1 and 2) residents reviewed. This failure placed residents at risk for misappropriation of medications, missed medications and possible diversion of controlled substances.

Inspectors wroteBased on interviews, observations and record review, facility staff failed to perform hand hygiene during medication administration for 2 of 3 (Staff C and D) staff reviewed for infection control. This failure placed residents at risk for the spread of infection and a diminished quality of life.

Inspectors wrote3) Resident 75 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively moderately impaired. Review of Resident 75's EHR documented them as Responsible Party. A progress note by Staff F, SSD, dated 06/03/2025, documented he provided the family with paperwork and contact information so they could begin the process of becoming Resident 75's legal representative. On 06/06/2025 at 10:49 AM, Staff F said Resident 75 did not have an advanced directive. Staff F said he did not offer information to Resident 75 or their family about establishing a POA during the initial care conference, and said the information was not provided until recently in June 2025. On 06/09/2025 at 11:07 AM, Staff B, DNS, said her expectation was that advanced directives be addressed on admission, including offering information about formulating a POA. [...]

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' complaints verbalized during Resident Council (RC) meeting for 4 of 6 months (December 2024, January, February and April 2025) The failure to initiate, log, investigate verbalized concerns, inform residents of their findings and actions taken, if any, prevented the facility from identifying care trends and determining if actions taken were effective in resolving the reported issues. These failures resulted in residents verbalizing the same complaints for multiple months without resolution, and placed residents at risk of feeling frustrated, unimportant and unheard, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman (resident advocates) occurred for residents transferred to the hospital, for 2 of 2 residents (Residents 19 & 25) reviewed for hospitalization. This failure placed residents at risk of a lack of advocacy and possible unidentified or unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR, a screening tool used to identify behavioral healthcare needs) were completed prior to admission and/or accurately reflected residents' mental health diagnoses for 7 of 8 residents (Residents 67, 53, 69, 78, 44, 54, & 19) reviewed for PASRR. These failure placed residents at risk for inappropriate placement, unmet behavioral healthcare needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure routine assessment and monitoring of skin conditions and implementation of interventions for 1 of 2 residents (Resident 67) reviewed for non-pressure skin, to provide bowel care in accordance with physicians' orders and facility protocol for 4 of 8 residents (Residents 67, 41, 45 & 283) reviewed for bowel management, and to effectively communicate, collaborate, and implement coordinated hospice plans of care for 2 of 2 (Residents 26 & 11) reviewed for Hospice services. These failures placed residents at risk for unidentified decline and/or delayed treatment and healing of non-pressure skin conditions, abdominal pain, decreased appetite, other negative outcomes related to untreated constipation, and unmet end of life care needs related to hospice services.

Inspectors wrote<Fluid Intake> Resident 41 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact, had a diagnosis of end stage renal disease, and required dialysis during the assessment period. An end stage renal disease care plan, revised 05/01/2025, had a goal that the resident would not have any signs and symptoms (s/sx) of fluid volume overload or fluid volume deficit through the next review. Interventions included dialysis three times a week, monitoring for s/sx of hypervolemia (excessive fluid in the body) and hypovolemia (low levels of fluid in the body caused by various factors including dehydration.) A nutritional risk care plan, revised 05/01/2025, documented the resident was on a 1500 milliliter (ml)/day fluid restriction and directed staff to record food and fluid intake. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide restorative nursing services for 2 of 2 residents (Residents 8 and 61) reviewed for limited range of motion. The failure to have sufficient qualified staff to provide restorative nursing services resulted in the therapy department not referring residents for restorative nursing programs, who they acknowledged were at risk for declines in range of motion (ROM), contracture formation/progression, and would have been referred for and benefited from restorative services, had sufficient staff been available to provide them. This failure placed residents at risk for decreased ROM, contractures, impaired skin integrity, increased dependence on staff for care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Residents 39, 70, & 28) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to honor resident rights related to medical appointments for 1 of 1 resident (Resident 70) reviewed for resident rights. This failure placed residents at risk of delay in care, emotional upset, and a diminished quality of life.

Inspectors wrote2) Resident 52 was admitted to the facility on [DATE] and has a diagnosis of depression. Resident 52's Quarterly MDS, dated [DATE] documented the resident was cognitively intact and was dependent to moderate assist with activities of daily living. Resident 52's EHR documented Sertraline, an antidepressant, was ordered on 02/24/2025 and the consent was signed on 03/21/2025. On 06/09/2025 at 9:49 AM Staff C, RCM/RN said we should have had a consent done when the order was placed. I am not sure why this was missed. On 06/09/2025 at 11:07 AM Staff B, Director of Nursing Service said the expectation was for the resident provide consent before the medication was given. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored, documented on and/or monthly pharmacist recommendations were acted upon timely, for 2 of 5 residents (Residents 54 &19) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage, increase in side effects without intervention, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours for 1 of 2 resident (Resident 3) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk for abuse and neglect.

Inspectors wrote2) Resident 67 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, had Stage 3 (Full-thickness skin loss in which fat is visible in the ulcer) and Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure injuries, required substantial to maximal assistance with bed mobility, and had an indwelling urinary catheter. A Urinary Incontinence and Indwelling Catheter care area assessment, completed 03/04/2025, documented Resident 67 required an indwelling catheter secondary to Stage 3 and Stage 4 pressure injuries to the sacrum and right buttock. Review of the urinary catheter care plan, revised 04/17/2025, showed there was no indication or justification for use documented. The goals were identified as: [...]

Inspectors wrote3) On 06/05/2025 at 8:06 AM, during a medication administration observation and record review, it was noted that Resident 450 had a current order for Aspirin 81 mg tablet, in a chewable form. On 06/05/2025 at 8:15 AM, Staff Q, LPN, provided Resident 450 with a small plastic cup with multiple medications in it, including the chewable Aspirin. Resident 450 was observed taking all the medications with a drink of water, including the chewable medication. On 06/05/2025 at 8:36 AM, Staff Q, regarding the chewable medication being swallowed and not chewed, said Resident 450 requests to take them all together. Staff Q said she had to give them the chewable form of the medication, rather than the non-chewable form, because that was how it was ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure injuries (PIs) were consistently assessed, and ordered pressure redistribution measures and equipment were in place and functional for 1 of 4 residents (Resident 67) reviewed for PIs. The failure to ensure an ordered low air loss mattress was in place and functional and to routinely assess identified PIs, detracted from the ability to determine if current treatments and interventions were effective and appropriate. This failure placed residents at risk for prolonged wound healing, unidentified decline, and development of avoidable PIs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents admitted with indwelling catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for catheter removal as soon as possible, and to ensure clinical condition/ justification existed for continued use for 1 of 1 resident (Resident 67) reviewed for urinary catheters. These failures placed residents at risk for unnecessary catheterization, urinary tract infections, and a decreased quality of life.

Inspectors wrote3) Resident 283 admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 283 was severely cognitively impaired. Resident 283 was on hospice services (end of life care). Resident 283 had orders for morphine (pain reliever) oral solution, by mouth every 1 hours as needed for breakthrough pain; dyspnea (shortness of breath). Review of Resident 283's MAR, from 05/22/2025 through 06/05/2025, showed morphine was administered with documented pain on 05/24/2025, 05/26/2025, 05/27/2025, 05/28/2025, 05/29/2025, 05/30/2025, 06/01/2025, 06/02/2025 and 06/05/2025. Resident 283's May 2025 and June 2025 MARs also showed staff were ordered to provide NPI to reduce pain and document the effectiveness. Interventions included repositioning, relaxation, diversional activities and redirection. Staff were instructed to document the NPI intervention and effectiveness as needed. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and label medications appropriately and discard expired medications for 2 of 5 medication carts (Medication Carts A2 & A3) reviewed. These failures placed residents at risk of receiving expired or less effective medications, and inappropriate access to medication.

Inspectors wroteBased on interview and record review the facility failed to store food for residents in accordance with professional standards for 5 of 5 refrigeration/freezer units (A1/A2, A3, B3, Walk in Cooler and Walk in Freezer) reviewed for food service safety. The failure to maintain documented refrigerator temperature logs placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff-maintained infection control practices during dressing changes for 1 of 3 wound cares observed, during meal tray delivery for 1 of 5 meal tray observations, and that regular temperature checks of the washing machines were complete for washing machines for for 1 of 1 laundry room reviewed for infection control. This failure placed residents at risk for the spread of infection and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement the plan of care for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for clinical complications, discomfort, lack of nutrition and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications to prevent seizures were administered per physician orders for 1 of 3 residents (Resident 6) reviewed for quality care. Resident 6 experienced harm when they were found unresponsive, required Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and was hospitalized when their medication for seizures were not administered for multiple doses due to the unavailability of the medications, resident refusals, and failure to notify the physician of the omissions. This failure placed all residents at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 6 staff members (Staff B, C and D) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading COVID 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with bathing, dressing and personal hygiene for 2 of 4 residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for poor hygiene, loss of dignity and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of physical restraints for 3 of 3 residents (Resident 1, 2 and 3) when medical devices prevented the residents from freedom of movement. This failure placed the residents at risk for injury, frustration, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and take timely action to prevent the development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) experienced by 1 of 1 closed record Resident reviewed for wound care. Resident 1 experienced actual harm when they developed pressure ulcers to both heels which required hospitalization for surgical intervention, intravenous (administered through the vein) antibiotics and below the knee amputation (BKA) of their right lower extremity (RLE). These failures placed residents at risk for pressure ulcer development, deterioration of existing pressure ulcers, pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care plan interventions for 2 of 3 residents (Resident 2 and 3) reviewed for quality of care. This failure placed residents at risk for poor hygiene, clinical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment was safe and free from hazards for 17 of 17 sampled residents (1 ,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) residing in the facility's locked dementia unit. Resident 1 experienced harm when they sustained a significant second degree burn (burn that affects the epidermis [outer layer of skin] and the dermis [middle layer of skin] to the left hip when they were found unsupervised seated on a baseboard heater. This failure placed all residents on the dementia unit at risk for serious injury and decreased quality of life and constituted an Immediate Jeopardy (IJ). [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy to prevent resident elopement for 1 of 3 residents (Resident 4) reviewed for accidents. This failure placed residents at risk of elopement, accidents and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to assess and treat pain for 1 of 3 residents (Resident 1) reviewed for pain. Failure to implement interventions to reduce pain, including administration of pain medication placed residents at risk of experiencing episodes of untreated pain and for a diminshed quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice to the resident, the resident representatives, and representative of the Office of the State Long-Term Care Ombudsman of an emergency transfer for 1 of 3 residents (1) reviewed for hospitalizations. This failure placed residents and/or their representatives at risk of not being able to make informed decisions about transfers and prohibited access to an advocate who could inform the resident/representative of their options and rights.

Inspectors wroteBased on interview and record review, the facility failed to consider re-admission of a resident after an unplanned hospitalization for 1 of 1 sample residents (1) reviewed for permitting residents to return to the facility. This failure placed residents at risk for increased anxiety related to being placed in an unfamiliar environment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 4 of 4 sampled residents (Residents 4, 5,19 and 24) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 32 sample residents (Residents 129 & 69) reviewed. Facility nurses failed to obtain, accurately transcribe, follow, and/or clarify physician's orders when indicated. The facility failed ensure nurses only signed for tasks that were completed. These failures placed residents at risk for medication errors, delays in treatment, unmet care needs and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide services to maintain vision for 2 of 2 sampled residents (Residents 50 and 69) reviewed for vision/hearing. This failure placed residents at risk of inability to complete activities of daily living, a heightened risk of accidents and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 4 residents (Residents 24, 63, 128 & 67) interviewed, and 2 staff (Staff C & Staff D) interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADLs) including showers, nail care and shaving. These failures placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were recorded for 1 of 2 refrigerators in the locked medication rooms. This failure placed residents at risk for receiving medications that were not properly stored.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and served under safe and sanitary conditions in one of one kitchen. These failures placed residents at potential risk for cross contamination, food borne illnesses and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to honor bathing and room preferences for 2 of 4 sampled residents (Residents 24 and 74) reviewed for choices. This failure placed residents at risk for poor hygiene, diminished quality of life and not being able to make choices considered important by the resident.

Inspectors wroteBased on interview and record review, the facility failed to notify 1 of 1 sampled resident (Resident 19), who was a Medicaid recipient, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed the resident at risk for personal financial liability for their care and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to initiate a resident grievance for 1 of 1 sampled resident (Resident 74) reviewed for grievances. This failure placed the resident at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow the recommendations of the Preadmission Screen and Resident Review (PASARR, an in-depth tool to evaluate psychosocial and psychiatric need) Level II, for 1 of 2 residents (Resident 30) reviewed for PASARR. This failure placed residents at risk of not receiving necessary services to meet their mental health and intellectual disability care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (CP), within 48 hours of admission, that provided the minimum healthcare information necessary to meet residents' immediate care needs for 1 of 6 residents (Resident 129) reviewed, who recently admitted to the facility. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure fluid intake was accurately monitored, documented, and assessed for 1 of 1 resident (Resident 129) reviewed with a fluid restriction. The failure to accurately record fluid intake and to calculate the resident's total 24-hour fluid intake, precluded staff from determining if Resident 129 was adherent with or was exceeding the ordered fluid restriction. This placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unidentified education needs and other medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 2 residents (Resident 129) reviewed for respiratory care. Facility staffs' administration of oxygen without an order for oxygen, placed residents at risk for side effects related to oxygen therapy, respiratory compromise and/or unmet respiratory needs.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services for 1 of 3 residents (Resident 30) reviewed for mood and behavior. The facility failed to monitor for mental health needs and coordinate necessary psychiatric consult/services. These failures placed residents at risk for unmet psychosocial needs, an increase in anxiety, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and deliver food in a manner that conserved the nutritive value, palatability, an appetizing appearance, and that ensured meal temperatures were maintained for 6 of 6 residents (Residents 10, 54, 13, 23, 39 & 60) reviewed with pureed diets, and for 1 of 6 residents (Resident 46) reviewed for food quality. Dietary staffs' failure to follow written recipes when preparing pureed diets, to test and record holding temperatures including the time the food temperature was checked, and to ensure foods were not overcooked, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 2 of 2 sampled residents (Residents 24 and 50) received foods that accommodated the residents' preferences and allergies. This failure placed the resident at risk for meal dissatisfaction, allergic reaction and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately provide specialized diets for 3 randomly observed residents (Resident 18, 69 and 428) during meal service. This failure placed the residents at risk for complications of their medical conditions, weight loss/gain and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 2 of 32 days reviewed and failed to meet the State RN staffing requirement of 24-Hour RN coverage for 32 of 32 days reviewed for RN staffing. This failure placed residents at risk for delay in resident assessmnents, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs.