A list of the most recent deficiencies for Bonnie Brae Skilled Nursing. 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 | 2024-02-05 | 2024-02-23 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-24 | 2024-02-23 | 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 | 2024-01-24 | 2024-02-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-01-24 | 2024-02-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-02-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-11 | 2024-02-11 | 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 | 2024-01-11 | 2024-02-11 | 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 | 2024-01-11 | 2024-02-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-11 | 2024-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-01-11 | 2024-02-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-12-03 | 2022-04-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-12-03 | 2021-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-03 | 2021-12-28 | 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 | 2021-12-03 | 2021-12-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-03 | 2021-12-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-03 | 2021-12-28 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-12-03 | 2021-12-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-03 | 2021-12-28 | 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 | 2021-12-03 | 2021-12-28 | 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 | 2021-12-03 | 2021-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-03 | 2021-12-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-12-03 | 2021-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-03 | 2021-12-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-06 | 2021-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-22 | 2019-07-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-04-22 | 2019-07-19 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-04-22 | 2019-06-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-04-22 | 2019-06-24 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-22 | 2019-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-22 | 2019-06-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-22 | 2019-06-24 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-04-22 | 2019-06-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-22 | 2019-06-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-22 | 2019-06-24 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-04-22 | 2019-06-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-22 | 2019-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-22 | 2019-06-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-04-22 | 2019-06-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-04-22 | 2019-06-24 | N |
| Have policies on smoking. | Health | 2019-04-22 | 2019-06-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-30 | 2019-05-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-30 | 2019-05-24 | 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 | 2019-04-30 | 2019-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-30 | 2019-05-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-04-30 | 2019-05-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-30 | 2019-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-30 | 2019-05-24 | N |
