A list of the most recent deficiencies for Brandel Manor. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-29 | 2023-12-12 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-11-29 | 2023-12-12 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-06-13 | 2023-06-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-13 | 2023-06-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-23 | 2023-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-02-10 | Y |
| 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 | 2022-12-30 | 2023-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-14 | 2022-10-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-06 | 2022-10-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-21 | 2022-09-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-03 | 2022-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-03 | 2022-07-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-03 | 2022-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-05 | 2021-09-17 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-05 | 2019-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-05 | 2019-12-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-05 | 2019-12-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-05 | 2019-12-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-25 | 2019-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-25 | 2019-12-13 | 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 | 2019-10-25 | 2019-12-13 | 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 | 2019-10-25 | 2019-12-13 | 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 | 2019-10-25 | 2019-12-13 | 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 | 2019-10-25 | 2019-12-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-10-25 | 2019-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-25 | 2019-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-25 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-25 | 2019-12-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-25 | 2019-12-13 | N |
| Keep all essential equipment working safely. | Health | 2019-10-25 | 2019-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-19 | 2018-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-19 | 2018-12-28 | 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 | 2018-10-19 | 2018-12-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-19 | 2018-12-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-19 | 2018-12-28 | 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 | 2018-10-19 | 2018-12-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-19 | 2018-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-19 | 2018-12-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-19 | 2018-12-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-06 | 2018-12-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-06 | 2018-12-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-12-06 | 2018-12-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-06 | 2018-12-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-13 | 2017-12-18 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-13 | 2017-12-18 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-13 | 2017-12-18 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2017-10-25 | 2017-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-10-25 | 2017-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-10-25 | 2017-11-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2017-10-25 | 2017-11-15 | N |
