Deficiency Records for Heritage at Brandon Place Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Heritage at Brandon Place Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-18 | 2023-06-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-18 | 2023-06-05 | 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 | 2023-04-18 | 2023-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-18 | 2023-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-18 | 2023-06-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-18 | 2023-06-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-08 | 2022-07-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-05 | 2021-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-05 | 2021-11-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-05 | 2021-11-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-05 | 2021-11-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-08-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-15 | 2021-08-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-15 | 2021-08-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-15 | 2021-08-30 | 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 | 2021-07-15 | 2021-08-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-15 | 2021-08-30 | 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 | 2021-07-15 | 2021-08-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-15 | 2021-08-30 | Y |
| 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 | 2021-07-15 | 2021-08-30 | Y |
| 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 | 2021-07-15 | 2021-08-30 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-07-15 | 2021-08-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-07-15 | 2021-08-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-15 | 2021-08-30 | Y |
| 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 | 2021-07-15 | 2021-08-30 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-07-15 | 2021-08-30 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-15 | 2021-08-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-15 | 2021-08-30 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-15 | 2021-08-30 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-07-15 | 2021-08-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-30 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-30 | 2021-08-30 | 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 | 2021-06-30 | 2021-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-30 | 2021-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2021-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-11 | 2019-07-01 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-03-11 | 2019-04-22 | 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 | 2019-03-11 | 2019-04-22 | 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 | 2019-03-11 | 2019-04-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-03-11 | 2019-04-22 | 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 | 2019-03-11 | 2019-04-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-03-11 | 2019-04-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-11 | 2019-04-22 | 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 | 2019-03-11 | 2019-04-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-11 | 2019-04-22 | 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 | 2019-03-11 | 2019-04-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-11 | 2019-04-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-11 | 2019-04-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-11 | 2019-04-22 | 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 | 2019-02-27 | 2019-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-27 | 2019-04-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-02-27 | 2019-04-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-27 | 2019-04-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-11 | 2019-04-15 | N |
