A list of the most recent deficiencies for Brandon Woods of Dartmouth. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-20 | 2024-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-20 | 2024-01-23 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-20 | 2024-01-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-20 | 2024-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-20 | 2024-01-23 | 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 | 2023-12-20 | 2024-01-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-20 | 2024-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-20 | 2024-01-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-02 | 2024-01-23 | 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 | 2024-01-02 | 2024-01-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-02 | 2024-01-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-02 | 2024-01-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-02 | 2024-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-02 | 2024-01-23 | 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 | 2021-08-18 | 2021-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-01 | 2021-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-18 | 2021-10-13 | 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 | 2021-08-18 | 2021-10-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-18 | 2021-10-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-18 | 2021-10-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-18 | 2021-10-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-18 | 2021-10-13 | 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 | 2021-08-18 | 2021-10-13 | 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 | 2021-08-18 | 2021-10-13 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-18 | 2021-10-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-18 | 2021-10-13 | 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 | 2021-08-18 | 2021-10-13 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-18 | 2021-10-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-01 | 2021-09-24 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Develop a communication plan. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-05-14 | 2019-06-21 | 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 | 2019-05-14 | 2019-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-14 | 2019-06-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-03 | 2019-05-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-03 | 2019-05-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-03 | 2019-05-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-03 | 2019-05-10 | 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 | 2019-04-03 | 2019-05-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-03 | 2019-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-03 | 2019-05-10 | N |
