A list of the most recent deficiencies for Focused Care at Brenham. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-15 | 2024-01-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-15 | 2024-01-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-15 | 2024-01-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-15 | 2024-01-12 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-29 | 2023-07-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-29 | 2023-07-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-29 | 2023-07-06 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-29 | 2023-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-09 | 2023-06-09 | Y |
| 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 | 2023-06-09 | 2023-06-09 | Y |
| 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 | 2023-02-28 | 2023-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-28 | 2023-02-28 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-22 | 2023-01-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-22 | 2023-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-22 | 2023-01-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-13 | 2022-12-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-08 | 2022-11-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-12 | 2022-05-13 | 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 | 2022-05-12 | 2022-05-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-12 | 2022-05-13 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-12 | 2022-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-05-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-05-12 | 2022-05-13 | N |
| 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 | 2022-05-12 | 2022-05-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-10 | 2021-04-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-20 | 2020-03-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-20 | 2020-03-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-20 | 2020-03-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-20 | 2020-03-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-20 | 2020-03-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-02-20 | 2020-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-03-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-02-20 | 2020-03-18 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2020-02-20 | 2020-03-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-20 | 2020-03-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
