Inspection Results » Fircrest Convalescent Hospital

Health Inspection on August 17, 2017 ^[1]

1. Widespread: Immediate jeopardy to the resident health or safety

   • Store, cook, and serve food in a safe and clean way. (Corrected N/A)
   • Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . (Corrected N/A)
   • Hire a qualified dietician. (Corrected 2017-10-31)

2. Pattern: Immediate jeopardy to the resident health or safety

   • Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. (Corrected 2017-10-31)

3. Isolated: Actual harm that is not immediate jeopardy

   • Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. (Corrected N/A)

4. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. (Corrected 2017-10-31)
   • Have enough nurses to care for every resident in a way that maximizes the resident's well being. (Corrected 2018-02-01)
   • Have a program that investigates, controls and keeps infection from spreading. (Corrected N/A)
   • Keep all essential equipment working safely. (Corrected 2018-02-01)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. (Corrected N/A)
   • Hire sufficient dietary support personnel. (Corrected N/A)

5. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. (Corrected 2018-02-01)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected N/A)
   • Make sure that special or therapeutic diets are ordered by the attending doctor. (Corrected N/A)
   • Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. (Corrected N/A)
   • Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. (Corrected N/A)
   • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Corrected 2017-10-31)
   • Offer other nutritional food to each resident who will not eat the food served. (Corrected 2018-02-01)
   • At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. (Corrected 2017-10-31)
   • Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. (Corrected N/A)
   • Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. (Corrected N/A)

6. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. (Corrected 2017-10-31)
   • Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. (Corrected 2018-02-01)
   • Ensure each resident receives an accurate assessment by a qualified health professional. (Corrected 2017-10-31)
   • Ensure residents maintain acceptable nutritional status. (Corrected 2017-10-31)