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Deficiency Records for Fireside Health Care Center
A list of the most recent deficiencies for Fireside Health Care Center. 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 Fireside Health Care Center. 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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-08-15 | 2024-09-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-07 | 2024-08-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-05-06 | 2024-06-03 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-15 | 2024-01-08 | 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 | 2023-12-15 | 2024-01-08 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-11-09 | 2023-12-07 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-11-09 | 2023-12-01 | 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 | 2023-11-09 | 2023-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-09 | 2023-12-01 | 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 | 2023-11-09 | 2023-12-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-09 | 2023-12-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-09 | 2023-12-01 | 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 | 2023-11-09 | 2023-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-09 | 2023-12-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-11-09 | 2023-12-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-11-09 | 2023-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2023-12-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Meet other general requirements. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-13 | 2023-12-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-18 | 2023-08-23 | 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 | 2023-07-18 | 2023-08-23 | Y |
| 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 | 2023-07-18 | 2023-08-23 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-07-18 | 2023-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-14 | 2023-07-28 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-14 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-14 | 2023-03-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-14 | 2023-03-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-02-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-02-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-12 | 2023-02-03 | 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 | 2023-01-12 | 2023-02-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-12 | 2023-02-03 | 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 | 2023-01-12 | 2023-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-02-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-12 | 2023-02-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-02-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-01-12 | 2023-02-03 | N |
| Post nurse staffing information every day. | Health | 2023-01-12 | 2023-02-03 | 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 | 2023-01-12 | 2023-02-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-01-12 | 2023-02-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-12 | 2023-02-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-01-12 | 2023-02-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-12 | 2023-02-03 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-18 | 2023-02-03 | 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 | 2023-01-18 | 2023-02-03 | 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 | 2023-01-18 | 2023-02-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-18 | 2023-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-18 | 2023-02-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-18 | 2023-02-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-18 | 2023-02-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-18 | 2023-02-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-18 | 2023-02-03 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-11-29 | 2022-12-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-27 | 2022-03-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-27 | 2022-03-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-27 | 2022-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-13 | 2022-03-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-13 | 2022-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-24 | 2022-01-07 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-12-11 | 2021-12-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-13 | 2021-10-27 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-12-13 | 2020-01-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-13 | 2020-01-13 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-12-13 | 2020-01-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-13 | 2020-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-13 | 2020-01-13 | 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 | 2019-12-13 | 2020-01-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-13 | 2020-01-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-12-13 | 2020-01-13 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-12-13 | 2020-01-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-12-13 | 2020-01-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-13 | 2020-01-13 | 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 | 2019-12-13 | 2020-01-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-13 | 2020-01-13 | 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 | 2019-12-13 | 2020-01-13 | 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 | 2019-12-13 | 2020-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-13 | 2020-01-13 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-13 | 2020-01-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-10 | 2020-01-08 | N |
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