A list of the most recent deficiencies for Brethren Retirement Community. 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 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 |
| 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 |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-09 | 2022-07-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-09 | 2022-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-09 | 2022-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-09 | 2022-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-09 | 2022-07-29 | 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 |
| 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 activities to meet all resident's needs. | 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 |
| 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 |
| 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 |
| Install an approved automatic sprinkler system. | 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-29 | 2018-05-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-03-29 | 2018-05-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-29 | 2018-05-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-03-29 | 2018-05-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-29 | 2018-05-17 | 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 | 2018-03-29 | 2018-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-29 | 2018-05-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-29 | 2018-05-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-03-29 | 2018-05-17 | 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 | 2018-03-29 | 2018-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-29 | 2018-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-29 | 2018-05-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-03-30 | 2018-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-30 | 2018-05-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-30 | 2018-05-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-30 | 2018-05-17 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-03-30 | 2018-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-30 | 2018-05-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-30 | 2018-05-17 | N |
