A list of the most recent deficiencies for Brendan House. 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? |
|---|---|---|---|---|
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2023-09-21 | 2023-11-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-14 | 2023-10-30 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-09-14 | 2023-10-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-29 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-14 | 2023-10-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-14 | 2023-10-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-14 | 2023-10-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-14 | 2023-10-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-21 | 2023-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-21 | 2023-10-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-22 | 2023-01-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-22 | 2023-01-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-22 | 2023-01-24 | 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 | 2022-12-22 | 2023-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-01-24 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-12-27 | 2023-01-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-27 | 2023-01-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-22 | 2022-12-22 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-11-10 | 2021-12-21 | N |
| 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 | 2021-11-10 | 2021-12-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-10 | 2021-12-21 | 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 | 2021-11-10 | 2021-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-10 | 2021-12-21 | 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 | 2021-11-10 | 2021-12-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-10 | 2021-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2021-12-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-16 | 2021-12-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-16 | 2021-12-21 | N |
