A list of the most recent deficiencies for Brittany 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 | 2023-08-25 | 2023-09-14 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-08 | 2023-06-21 | Y |
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 | 2023-06-06 | 2023-06-21 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-06 | 2023-06-21 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-06 | 2023-06-21 | 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 | 2022-06-08 | 2022-12-07 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-13 | 2022-07-08 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-13 | 2022-07-08 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-13 | 2022-07-08 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-13 | 2022-07-08 | N |
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-06-13 | 2022-07-08 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-13 | 2022-07-08 | 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 | 2022-06-13 | 2022-07-08 | 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 | 2022-06-08 | 2022-07-08 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
Provide and implement an infection prevention and control program. | Health | 2022-05-18 | 2022-06-20 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-22 | 2020-01-01 | N |
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 | 2019-11-22 | 2020-01-01 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-11-22 | 2020-01-01 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-22 | 2020-01-01 | N |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-11-22 | 2020-01-01 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-22 | 2020-01-01 | N |
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-11-22 | 2020-01-01 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-22 | 2020-01-01 | N |
Respond appropriately to all alleged violations. | Health | 2019-11-22 | 2020-01-01 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-22 | 2020-01-01 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-11-22 | 2020-01-01 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-22 | 2020-01-01 | 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 | 2019-11-22 | 2020-01-01 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-22 | 2020-01-01 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-22 | 2020-01-01 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-22 | 2020-01-01 | 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 | 2019-11-22 | 2020-01-01 | 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 | 2019-11-22 | 2020-01-01 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-22 | 2020-01-01 | 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 | 2019-11-22 | 2020-01-01 | N |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-11-22 | 2020-01-01 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-22 | 2020-01-01 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-22 | 2020-01-01 | N |
Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-11-22 | 2020-01-01 | N |
Provide and implement an infection prevention and control program. | Health | 2019-11-22 | 2020-01-01 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-20 | 2019-12-31 | N |