Deficiency Records for Brickyard Healthcare - Twelfth Street Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Brickyard Healthcare - Twelfth Street 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? |
---|---|---|---|---|
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-19 | 2023-12-15 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-19 | 2023-12-15 | N |
Provide properly protected cooking facilities. | Fire Safety | 2023-10-19 | 2023-12-01 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-19 | 2023-12-01 | N |
Have restrictions on the use of portable space heaters. | Fire Safety | 2023-10-19 | 2023-12-01 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-19 | 2023-12-01 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-26 | 2023-10-26 | 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 | 2023-09-26 | 2023-10-26 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-26 | 2023-10-26 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-26 | 2023-10-26 | N |
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-09-26 | 2023-10-26 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-26 | 2023-10-26 | 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 | 2023-09-26 | 2023-10-26 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-26 | 2023-10-26 | N |
Keep all essential equipment working safely. | Health | 2023-09-26 | 2023-10-26 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-11 | 2022-06-24 | N |
Honor the resident's right to manage his or her financial affairs. | Health | 2022-05-11 | 2022-06-24 | 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 | 2022-05-11 | 2022-06-24 | N |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-11 | 2022-06-24 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-11 | 2022-06-24 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-11 | 2022-06-24 | 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 | 2022-05-11 | 2022-06-24 | N |
Provide activities to meet all resident's needs. | Health | 2022-05-11 | 2022-06-24 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-11 | 2022-06-24 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-11 | 2022-06-24 | 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 | 2022-05-11 | 2022-06-24 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-11 | 2022-06-24 | N |
Post nurse staffing information every day. | Health | 2022-05-11 | 2022-06-24 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-11 | 2022-06-24 | 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 | 2022-05-11 | 2022-06-24 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-11 | 2022-06-24 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-11 | 2022-06-24 | N |
Provide and implement an infection prevention and control program. | Health | 2022-05-11 | 2022-06-24 | N |
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-05-11 | 2022-06-24 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-11 | 2022-06-24 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-11 | 2022-06-24 | Y |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-24 | 2022-06-24 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-24 | 2022-06-24 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-14 | 2022-02-10 | Y |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-10 | 2021-07-02 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Meet other general requirements that are deficient. | Fire Safety | 2019-07-01 | 2019-08-06 | 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 | 2019-07-01 | 2019-08-06 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-01 | 2019-08-06 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-24 | 2019-06-23 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-24 | 2019-06-23 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-24 | 2019-06-23 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-24 | 2019-06-23 | 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 | 2019-05-24 | 2019-06-23 | N |
Provide and implement an infection prevention and control program. | Health | 2019-05-24 | 2019-06-23 | N |
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-24 | 2019-06-23 | N |