A list of the most recent deficiencies for Complete Care at Brackenville LLC. 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-25 | 2022-09-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-25 | 2022-09-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-07-25 | 2022-09-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-25 | 2022-09-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-25 | 2022-09-13 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-07-25 | 2022-09-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-25 | 2022-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-25 | 2022-09-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-07-25 | 2022-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-25 | 2022-09-13 | 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 | 2022-07-25 | 2022-09-13 | N |
| Provide or obtain dental services for each resident. | Health | 2022-07-25 | 2022-09-13 | 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 | 2022-07-25 | 2022-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-25 | 2022-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-25 | 2022-09-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-07-25 | 2022-09-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-18 | 2021-06-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-18 | 2021-06-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-17 | 2019-07-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-17 | 2019-07-31 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2019-04-17 | 2019-07-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-17 | 2019-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-17 | 2019-07-31 | 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 | 2019-04-17 | 2019-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-17 | 2019-07-31 | 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 | 2019-04-17 | 2019-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-17 | 2019-07-31 | 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 | 2019-04-17 | 2019-07-31 | 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 | 2019-04-17 | 2019-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-17 | 2019-07-31 | 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 | 2019-04-17 | 2019-07-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-17 | 2019-07-31 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-04-17 | 2019-07-31 | 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 | 2019-04-17 | 2019-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-17 | 2019-07-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-17 | 2019-07-31 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-04-17 | 2019-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-17 | 2019-07-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-10 | 2019-04-26 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-04-11 | 2018-06-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-04-11 | 2018-06-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-04-11 | 2018-06-18 | 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 | 2018-04-11 | 2018-06-18 | 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 | 2018-04-11 | 2018-06-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-11 | 2018-06-18 | 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 | 2018-04-11 | 2018-06-18 | 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 | 2018-04-11 | 2018-06-18 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-04-11 | 2018-06-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-11 | 2018-06-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-11 | 2018-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-11 | 2018-06-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-04-10 | 2018-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-10 | 2018-05-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-10 | 2018-05-01 | N |
