Deficiency Records for Springs Rehabilitation at Brandywine
Updated as of October 01, 2020
This is not the most recent data for Springs Rehabilitation at Brandywine. For the most recent information, click here.
A list of the most recent deficiencies for Springs Rehabilitation at Brandywine. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-18 | 2020-02-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-12-18 | 2020-02-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-12-18 | 2020-02-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-18 | 2020-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-18 | 2020-02-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-18 | 2020-02-18 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-12-18 | 2020-02-18 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-12-18 | 2020-02-18 | 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 | 2019-12-18 | 2020-02-18 | 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 | 2019-12-18 | 2020-02-18 | 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 | 2019-12-18 | 2020-02-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-18 | 2020-02-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-18 | 2020-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-18 | 2020-02-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-18 | 2020-02-18 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-12-18 | 2020-02-18 | 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 | 2019-12-18 | 2020-02-18 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-10 | 2020-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-10 | 2020-01-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-10 | 2020-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2019-01-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-25 | 2019-01-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-25 | 2019-01-26 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-25 | 2018-12-26 | 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 | 2018-10-25 | 2018-12-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-25 | 2018-12-26 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-10-25 | 2018-12-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-25 | 2018-12-26 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-10-25 | 2018-12-26 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-25 | 2018-12-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-25 | 2018-12-26 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-10-25 | 2018-12-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-25 | 2018-12-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-25 | 2018-12-26 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-10-25 | 2018-12-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-25 | 2018-12-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-25 | 2018-12-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-10-25 | 2018-12-26 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-10-25 | 2018-12-26 | Y |
| Provide or obtain dental services for each resident. | Health | 2018-10-25 | 2018-12-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-25 | 2018-10-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-04-25 | 2018-10-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-04-25 | 2018-10-08 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-04-25 | 2018-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-25 | 2018-10-08 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-25 | 2018-10-08 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-25 | 2018-10-08 | Y |
| 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 | 2018-04-25 | 2018-10-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-07-19 | 2018-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-19 | 2018-07-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2018-04-25 | 2018-07-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-04-25 | 2018-07-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-25 | 2018-07-20 | Y |
| 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 | 2018-04-25 | 2018-07-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-25 | 2018-07-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-25 | 2018-07-20 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-19 | 2017-09-11 | Y |
| Provide housekeeping and maintenance services. | Health | 2017-07-19 | 2017-09-11 | Y |
| Maintain comfortable and safe temperature levels. | Health | 2017-07-19 | 2017-09-11 | Y |
| Maintain comfortable sound levels. | Health | 2017-07-19 | 2017-09-11 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-19 | 2017-09-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-07-19 | 2017-09-11 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-19 | 2017-09-11 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-07-19 | 2017-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-19 | 2017-09-11 | Y |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2017-07-19 | 2017-09-11 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-19 | 2017-09-11 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-07-19 | 2017-09-11 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-07-19 | 2017-09-11 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-19 | 2017-09-11 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-19 | 2017-09-11 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-07-19 | 2017-09-11 | Y |
