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Deficiency Records for Fircrest Nursing Facility
A list of the most recent deficiencies for Fircrest Nursing Facility. 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 Fircrest Nursing Facility. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2023-11-06 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-08-03 | 2023-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-07 | 2023-09-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-07 | 2023-09-08 | 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 | 2023-08-07 | 2023-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-07 | 2023-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-07 | 2023-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-07 | 2023-09-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Establish methods for sharing information. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Meet other general requirements. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-03 | 2023-09-07 | 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 | 2023-08-03 | 2023-09-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-03 | 2023-09-07 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-02-28 | 2022-04-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-28 | 2022-04-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-28 | 2022-04-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-28 | 2022-04-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-28 | 2022-04-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-02-28 | 2022-04-12 | N |
| Meet other general requirements. | Fire Safety | 2022-02-22 | 2022-03-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-22 | 2022-03-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-22 | 2022-03-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-22 | 2022-03-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-22 | 2022-03-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-08-21 | 2019-10-16 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-08-21 | 2019-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-21 | 2019-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-21 | 2019-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-21 | 2019-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-21 | 2019-10-16 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-15 | 2019-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-15 | 2019-09-20 | 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 | 2019-08-15 | 2019-09-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-15 | 2019-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-15 | 2019-09-20 | N |
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