A list of the most recent deficiencies for 24th Place. 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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-15 | 2023-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-15 | 2023-05-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-15 | 2023-05-15 | 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 | 2023-03-15 | 2023-05-15 | 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 | 2023-03-15 | 2023-05-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-15 | 2023-05-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-15 | 2023-05-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-15 | 2023-05-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-15 | 2023-05-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-20 | 2022-02-15 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-12-20 | 2022-02-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-12-20 | 2022-02-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-12-20 | 2022-02-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-12-20 | 2022-02-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-12-20 | 2022-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-20 | 2022-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-20 | 2022-02-15 | 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 | 2021-12-20 | 2022-02-15 | 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 | 2021-12-20 | 2022-02-15 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-12-20 | 2022-02-15 | N |
| Report COVID19 data to residents and families. | Health | 2021-12-20 | 2022-02-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-20 | 2022-02-15 | Y |
| 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 | 2021-12-20 | 2022-02-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-20 | 2022-02-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-20 | 2022-02-15 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-12-20 | 2022-02-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-20 | 2022-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-20 | 2022-02-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-20 | 2022-02-15 | 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 | 2021-12-20 | 2022-02-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-20 | 2022-02-15 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-20 | 2022-02-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-20 | 2022-02-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-02-15 | Y |
| Keep all essential equipment working safely. | Health | 2021-12-20 | 2022-02-15 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-14 | 2022-02-15 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-12-14 | 2022-02-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-14 | 2022-02-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-01 | 2019-11-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-01 | 2019-11-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-10-01 | 2019-11-01 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-10-01 | 2019-11-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-01 | 2019-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-01 | 2019-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-01 | 2019-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-01 | 2019-11-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-01 | 2019-11-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-01 | 2019-11-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | 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 | 2019-10-01 | 2019-11-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-10-01 | 2019-11-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-10-01 | 2019-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-01 | 2019-11-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-01 | 2019-11-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-26 | 2019-11-01 | 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 | 2019-09-26 | 2019-11-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
