Deficiency Records for Springs Rehabilitation at Brandywine
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-08 | 2024-01-03 | Y |
| 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 | 2023-11-08 | 2024-01-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-08 | 2024-01-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-08 | 2024-01-03 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-11-08 | 2024-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-08 | 2024-01-03 | N |
| 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 | 2023-11-08 | 2024-01-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-08 | 2024-01-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2024-01-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-08 | 2023-12-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-12-26 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-11-08 | 2023-12-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-08 | 2023-12-26 | Y |
| 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 | 2023-11-08 | 2023-12-26 | 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 | 2023-11-08 | 2023-12-26 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-11-08 | 2023-12-26 | N |
| Keep all essential equipment working safely. | Health | 2023-11-08 | 2023-12-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-08 | 2023-12-26 | 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 | 2023-11-08 | 2023-12-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-08 | 2023-12-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-08 | 2023-12-26 | 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 | 2023-11-08 | 2023-12-26 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-11-09 | 2023-12-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-09 | 2023-12-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-09 | 2023-12-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-09 | 2023-12-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-09 | 2023-12-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-09 | 2023-12-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2022-09-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-06 | 2021-06-21 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-05-06 | 2021-06-21 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-05-06 | 2021-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-06 | 2021-06-21 | 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 | 2021-05-06 | 2021-06-21 | Y |
| 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 |
| 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 | 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 |
| 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 |
