Fireside Health Care Center

Inspectors wroteBased on interview, and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS-a resident assessment tool) Assessment timely for five of five sampled residents (Resident 23, 33, 39, 41 and 43) reviewed under the Resident Assessment task. This deficient practice had the potential to negatively affect the provision of necessary care and services needed Resident 23, 33, 39, 41 and 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored under sanitary condition and that food preparation equipment was clean when:An open whole egg mayonnaise and butter milk ranch dressing did not have the use by date on them. Ice scoop did not have a cleaned date on it and ice scoop cleaning logs for the month of 1/2026 had dates Saturday and Sunday blocked, blackened out and no initials noted. These failures had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 59 of 60 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 28 out of 32 rooms met the 80 square feet (sq. ft.) per resident in multiple resident rooms. These 28 rooms consisted of twenty-five 2-bed rooms, two 3-bed rooms and one 4-bed room. This deficient practice had the potential to result In inadequate space to provide safe nursing care and privacy for the residents. On 1/21/2026, the Administrator provided a copy of the Client Accommodation Analysis, dated 1/20/2026 and the facility letter requesting for continuation of room waiver. A review of the Client Accommodation Analysis indicated that 28 of 32 rooms did not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis showed the following:Rm# # of Beds Sq. Ft. Sq. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one of three sampled residents (Resident 77) the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN - provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility). This deficient practice had the potential to result in the facility not giving Resident 77 the information needed to decide if he or she would like to continue or refuse receiving the specific skilled services and have those options honored.

Inspectors wroteBased on observation and interview, the facility failed to ensure that dignity of the resident was maintained for one of seven sampled residents (Resident 3) in accordance with the facility's policy and procedures (P&P) titled Quality of Life -Dignity, revised 2/2025, by failing to maintain and protect residents privacy, including bodily privacy during assistance with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. This deficient practice violated the rights for privacy for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of seven sampled residents (Resident 7) in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered with revised date of 8/2025, by failing to have a care plan for Resident 7's apixaban (a medication that prevents dangerous blood clots from forming or getting bigger). This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician's orders to treat and provide treatment to one of one sampled resident's (Resident 73) right and left buttock pressure ulcers from 1/9/2026 to 1/13/2026. This deficient practice placed Resident 73 at risk for worsening of the pressure injury and infection.

Inspectors wroteBased on interview and record review, the facility failed to provide the correct liters of oxygen per physician order according to the physician order for one out of three sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 experiencing respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to effectively manage a resident's pain for one of one (1) sample resident, Resident 74, as evidenced by failing to:Re-assess Resident 74's pain level after administering Tylenol (Acetaminophen- a common over-the-counter analgesic [pain reliever]) used to treat mild-to-moderate pain) according to facility's policy and procedures (P&P) titled Pain Assessment and Management dated 08/2025. Administer Oxycodone HCI (a powerful opioid controlled pain reliever used for moderate to severe pain) Oral (by mouth) Tablet 5mg give 0.5 tablet by mouth every 6 hours as needed for moderate pain 4-7/10 Hold for sedation or RR<12 as ordered on 1/16/2026 when Resident 74 complained of eight out of 10 pain level (8/10-a numerical pain assessment where zero is no pain and 10 is severe pain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 5) who received dialysis (process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, by failing to:1. Administer Epogen per physician order2. Clarify with the physician if the facility or dialysis center was to administer Epogen (is an injectable prescription medicine that stimulates the bone marrow to produce red blood cell) to Resident 53. Communicate with the resident's dialysis center about Epogen being administered during dialysis treatment for Resident 5. [...]

Inspectors wroteBased on observations, interviews and record review, facility failed to ensure infection control practices were adhered to in accordance with professional standards of practice when:The facility failed to isolate(to separate individuals with a known or suspected contagious disease from those who are not infected to prevent the spread of illness) Resident 60 after the resident's urine tested positive (presence of) for Extended spectrum beta lactamase (ESBL - bacteria that produce enzymes making them resistant to many common antibiotics, such as penicillin's and cephalosporins, making infections harder to treat). Resident 60 was on the patio with other residents while she was positive for ESBL. These deficient practices placed the residents and staff at increased risk to contract ESBL, and/or hospitalization.

Inspectors wroteBased on interview and record review for one of three sampled residents (Resident 1), the facility failed to report an allegation of suspected abuse to the correct agencies within the time frame specified by the facility policy. This deficient practice had the potential to leave Resident 1 at risk of further suspected alleged abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to display and provide a copy of the current Administrators license as per regulation. This failure had the potential for residents, families, and Department of Public Health to be provided the wrong information regarding the current Administrator.

Inspectors wroteThe facility failed to take the appropriate corrective action to address grievances for two of two sampled residents (Residents 1 and 2) when: 1. Resident 1 complained about a missing cellphone and clothing 2. Resident 2 complained about missing clothing. 3. Facility failed to complete inventory list for Resident 1 upon admission to the facility. 4. The facility failed to investigate reports of missing property for Residents 1 and 2. As a result: 1. Resident 1 was angry about missing clothing and cellphone, and felt disconnected from the outside world 2. Resident 2 was angry about missing clothing.

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 1), facility failed to: 1. Monitored and supervised Resident 1 to prevent elopement (the act of leaving a facility unsupervised and without prior authorization). 2. Ensure the alarm system was functioning on two of five exits doors (Door C- [south side exit door leading to the front of the facility] and Door E [northside door, at the back of the facility leading to the alley]) to alert staff if a resident was eloping and or exiting the facility. 3. Ensure the alarm system was activated/functional on one of five exit doors (Door D- northside back of the facility exit door leading to the side street). 4. Ensure that the alarm system was checked for proper functionality for five of five exit doors. 5. Ensure that Resident 1's care plan was resident specific for possible elopement. [...]

Inspectors wroteBased on observation, interview, and record review for one of three sampled residents, Resident 2. The facility failed to waste an Ativan (medication used to treat anxiety) 0.5 mg(milligrams) per facility-controlled narcotic (a medication tightly controlled by the government because it may be abused or cause addiction) protocol. This deficient practice resulted in an inaccurate Ativan 0.5mg count for Resident 2.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 2), the facility failed to: 1. Follow up and ensure that a physician ordered oxycodone-APAP (controlled medication used to manage moderate to severe pain). 2. Administer Oxycodone-APAP to Resident 2 for 18 of 54 days, The facility was aware Resident 2 had verbalized and was experiencing eight out of 10 (8/10 - numerical pain assessment tool where 0 is no pain and 10 being the worst pain) pain level in both shoulders, neck, and the back. As a result, Resident 2 experienced pain, frustration, and was unable to attend/participate in activities.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review level I(PASRR -an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) was obtained and maintained in the residents chart for one of five sampled residents (Resident 61). This deficient practice had the potential to negatively affect the appropriated care and services rendered to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply neck brace at all times to Resident 122 according to the physician's order. Resident 122 was admitted to the facility with displaced fracture of second cervical vertebra (a broken bone in the neck), This failure had the potential to cause further injury and pain to Resident 122.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean the Bilevel positive airway pressure (Bipap- is a breathing device that helps people breathe when they have trouble on their own) machine for one of six residents, Resident 8. This deficient practice had the potential to cause respirartory infection to Resident 8.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure staff were competent in operating and cleaning a Bilevel positive airway pressure (Bipap- is a breathing device that helps people breathe when they have trouble on their own). 3. Ensure five of five staff (registered nurse supervisor 4 (RNS 4), licensed vocational nurse 3 (LVN 3), certified nursing assistant 4 (CNA 4), CNA 5, and rehabilitative nursing assistant 1 (RNA 1) providing care and services to residents had the current required Cardiopulmonary Resuscitation (CPR: a credential that qualifies the holder to perform a life-saving procedure on someone who cannot breathe on their own due to a near-drowning incident, suffocation, or a cardiac event) certification by the American Heart Association (AHA - trains healthcare professionals to meet national performance standards) and or required annual competencies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functional bed and a comfortable mattress for one of four sampled residents (Resident 8). The facility failed to ensure the resident's mattress was not worn out and the bed was not operating properly. This failure resulted in Resident 8 feeling very angry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 27) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level II (a person-centered evaluation that helps determine placement and specialized services) assessment was completed as required by PASRR Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment. This deficient practice of failing to complete PASRR Level II assessment for Resident 27 put Resident 27 at risk for not receiving the necessary care and specialized services tailored to Resident 27's needs.

Inspectors wroteBased on observation and, interview, facility failed to ensure two of 15 sampled Residents (Resident 17 and Resident 46) were in a hazard and clutter free environment by failing to ensure the residents room entrance was accessible to staff and the residents. This deficient practice had the potential to place Residents 17 and 46 at risk from unnecessary accidents, hazards, and delay in necessary emergency care and/or treatment that could result in poor outcomes, unnecessary hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 41) who was incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) by failing to assess and monitor Resident 41's urinary catheter for signs of infections. This deficient practice had the potential for delayed UTI treatment and reoccurrence of UTIs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of ten sampled residents (Resident 220) received the appropriate treatment and services needed to maintain and prevent gastrostomy tube (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) complications. By failing to label the resident's tube feeding syringe with an open date. This deficient practice had the potential to cause a spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to ensure: 1) Residents' shower room were always maintained in safe and hygienic conditions; the facility utilized the resident shower room to store a heavy-duty large garbage can designated for dirty diaper only. 2) The for patients use only restroom located between rooms [ROOM NUMBERS] was not used by staff or visitors to prevent cross contamination. 3) The sink in the restroom located between rooms [ROOM NUMBERS] was not used to rinse urinals after emptying the contents in the toilet. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure Restorative Nurse Assistant 1 (RNA - assists the resident in performing tasks that restore or maintain physical function) had been properly certified and trained in the RNA training program prior to providing care to residents. This deficient practice had the potential to harm residents when RNA 1 performed inadequate techniques in therapeutic rehabilitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 28 out of 32 rooms met the 80 square feet (sq. ft.) per resident in multiple resident rooms. These 28 rooms consisted of twenty-five 2-bed rooms, two 3-bed rooms and one 4-bed room. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's orders were carried out by failing to provide one of three sampled residents (Resident 1) with a hospice (A program that provides care for people who are near the end of their life and have stopped treatment. Hospice offers physical, emotional, social, and spiritual support for patients and their families) agency during/upon discharge as ordered. This deficient practice resulted in Resident 1 receiving incomplete discharge information which caused confusion.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Return medications after discharged from the facility for four of eight sampled residents Residents 3, 5, 6, 7 and 8), and 2. Destroy medications per policy for four of eight sampled residents Residents 3, 5, 6, 7 and 8). This deficient practice led to multiple medications left behind in the medication storage room accessible to all staff with access to the room.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Secure a discharged residents ' -controlled substances (medications that are high risk for addiction and dependence and can cause respiratory distress and death when taken in high doses) as per facility protocol for one of eight sampled residents (Resident 4). 2. Store discontinued controlled substances per facility policy. These deficient practices resulted in these controlled substances easily accessible to all staff with access to the medication storage room and potential for drug diversion.

Inspectors wroteBased on interview, and record review the facility failed to ensure the Medical Director had filed an application with the State Licensing and Certification department ' s Centralized Applications Branch (CAB). This failure resulted in the Medical Director (MD) not being listed in the Electronic Licensing Management System (ELMS) and had the potential to affect resident care and medical oversight in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the resident as soon as practicable. The facility also failed to provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of the transfer and discharge from the facility for one out of the three sampled residents (Resident 1). This deficient practice denied the residents additional protections from being inappropriately discharged and caused Resident 1 to have feelings of confusion and become upset.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one of three sampled residents (Resident 1) by failing to: Develop an individualized/person-centered care plan with goals and interventions upon readmission for discharge plan to ensure a smooth and safe transition from the facility to the post-discharge setting. This failure resulted in Resident feeling confused and anxious. Cross reference F623.

Inspectors wroteBased on interview and record review the facility failed to provide physician documentation to support a facility-initiated discharge for one of two sampled residents, Resident 1. This deficient practice placed the resident at risk for an unsafe discharge.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) who has severe cognitive impairment with no capacity to make decisions in accordance with facility's abuse policy and procedures. By failing to: 1. Implement the facility's policy and procedures (P&P) Abuse Prevention and Prohibition Program to protect residents from abuse by screening and training caregivers (a person who tends to the needs or concerns of a person with short- or long-term limitations due to illness, injury, or disability) two of two caregivers (CG1 and CG2). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse Prevention and Prohibition Program dated 10/24/2022, by failing to report the unusual occurrence of a resident-to-caregiver altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 7/23/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to report alleged abuse to the abuse coordinator and state agency for one of three residents sampled residents (Resident 1). This deficient practice placed other residents at risk for potential alleged abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge plan that included visits by an operating hospice (medical care for people with an anticipated life expectancy of 6 months or less, when cure isn't an option, and the focus shifts to symptom management and quality of life) agency (HA1) for one of one sampled resident (Resident 1). The facility also failed to provide information about HA1 to Resident 1's family member. This deficient practice resulted in Resident 1 not receiving physical comfort and emotional, social, and spiritual support when nearing the end of life. Findings. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine was offered to one of six sampled residents (Resident 3). This deficient practice placed Resident 3 at a higher risk of possibly acquiring and transmitting influenza infection to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered/ re-offered and/or administered per facility ' s policy for one of six sampled residents (Resident 2). This deficient practice resulted COVID-19 infection to Resident 2 and placing other resident and staff at risk for COVID-19 infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide expiration dates on food packages, and remove expired food stored on the shelves in the kitchen. These deficient practices had the potential to cause food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedure (P&P) for food storage in resident's refrigerator to ensure the refrigerator temperature log was completed daily and food brought from outside was properly labeled and dated. Those deficient practices had the potential to cause food borne illnesses among the residents who consumed spoiled and expired food brought from outside of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's infection control program included a water management to monitor and test the water for disease causing pathogens (organisms that cause disease). This failure had a potential to place residents at risk for water-related healthcare-associated infections resulting from the growth and transmission of organisms.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 77) received written notice of room change prior to changing the resident's room. This deficient practice violated Resident 77 and Resident 77's Responsible Party's rights to receive written notice of the room change, including the reason for the change, before the resident's room in the facility was changed.

Inspectors wroteBased on observation, interview, and record review, one of two sampled residents (Resident 283) complained of uncomfortable noise levels within the facility. The deficient practice of loud noises had the potential to cause Resident 283 distress.

Inspectors wroteBased on interview and record review the facility failed to initiate and implement comprehensive care plans for two of six sampled residents (Residents 71 and 183), by failing to develop and implement care plans for: 1. Resident 71 for hospice (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally [serious illness leading to death] ill) care. 2. Resident 183 for smoking and pain management. These deficient practices had the potential to result in inconsistent implementation of care that may have resulted in injury or delay in the delivery of services for Residents 71 and 183.

Inspectors wroteBased on interview and record review the facility failed to update comprehensive care plan for Duloxetine (medication used to treat depression) 20mg (one thousandth of a gram) daily for one of two sampled resident (Resident 39). This deficient practice had the potential to cause inconsistent treatment in relation to this medication for Resident 39.

Inspectors wroteBased on observation, interview and record review the facility failed to order a dermatology (the branch of medicine concerned with the diagnosis, treatment, and prevention of diseases of the skin, hair, nails) consult for one of two sampled residents (Resident 48). This deficient practice may have delayed potential treatment for this abnormal growth on Resident 48's left shoulder.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedures (P&P) and complete smoking assessment to determine resident smoking-related privileges for one of three sampled residents (Resident 183) upon admission to the facility. This deficient practice had the potential for injury or a smoking related accident for Resident 183.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medication as per physician's order for two of four sampled residents (Resident 11 and Resident 53). This deficient practice had the potential to place resident at risk for feeling dizzy, upset stomach, or feeling weak for Resident 53 and medication error related to self-medication administration for Resident 11.

Inspectors wroteBased on interview and record review the facility failed to perform recommended gradual dose reduction (GDR-a stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed by a lower dose or if the dose or the medication can be discontinued) for the medication Duloxetine (medication used to treat depression) 20mg (one thousandth of a gram) daily for one of two sampled resident (Resident 39). This deficient practice could have caused too high or too low levels of the medication to manage Resident 39's symptoms.

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure (P&P) to ensure 1 of 2 sampled residents (Resident 71) had an interdisciplinary (IDT-a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) prior to entering hospice care program (a program focused on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life). This deficient practice had the potential for Resident 71's care needs including physical and emotional needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 28 out of 32 rooms met the 80 square feet (sq. ft.) per resident in multiple resident rooms. These 28 rooms consisted of twenty-five 2-bed rooms, two 3-bed rooms and one 4-bed room. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.