A list of the most recent deficiencies for Fircrest School, Pat N. 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 |
