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Deficiency Records for Brethren Retirement Community
View the most recent health deficiencies and inspection results for Brethren Retirement Community. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Brethren Retirement Community. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2025-09-19 | 2025-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-03-06 | 2025-04-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-06 | 2025-04-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2025-03-06 | 2025-04-14 | 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 | 2025-03-06 | 2025-04-14 | 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 | 2025-03-06 | 2025-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-06 | 2025-04-14 | 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 | 2025-03-06 | 2025-04-14 | 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 | 2025-03-06 | 2025-04-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-03-06 | 2025-04-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-03-06 | 2025-04-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-03-06 | 2025-04-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-03-06 | 2025-04-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-04-14 | 2025-03-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-18 | 2024-07-30 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-30 | 2023-07-17 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-13 | 2022-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-13 | 2022-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-13 | 2022-07-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-13 | 2022-07-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-13 | 2022-07-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-13 | 2022-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-13 | 2022-07-29 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-13 | 2022-07-29 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-16 | 2019-06-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-16 | 2019-06-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-16 | 2019-06-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-05-16 | 2019-06-26 | 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 | 2019-05-16 | 2019-06-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-16 | 2019-06-26 | 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 | 2019-05-16 | 2019-06-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-16 | 2019-06-26 | N |