JEFFREY & SUSAN BRUDNICK CENTER FOR

Performance Report

ADMINISTRATION

RESULTS
Standard Survey - 36 of 39 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 36

This nursing facility met 36 out of the 39 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 36. The statewide average facility score was 36.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
02/01/2024 D (F 658)
The services provided or arranged by the facility as outlined by the comprehensive care plan must meet professional standards of quality. (F 658)
Deficiency #2
02/01/2024 D (F 880 )
The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Identified incidents of infection and corrective measures must be recorded and the infection control program must be reviewed yearly and updated as necessary. (F 880 )

NURSING

RESULTS
Standard Survey - 26 of 33 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 26

This nursing facility met 26 out of the 33 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 26. The statewide average facility score was 27.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
12/22/2022 D (F 636 )
The facility conducts, initially and periodically, a comprehensive, accurate, standardized reproducible assessment of each resident?s functional capacity from direct observation and communication with the resident and direct care staff. (F 636 )
Deficiency #2
02/01/2024 D (F 637 )
The facility provides a prompt assessment after residents experience a significant change in physical or mental condition. (F 637 )
Deficiency #3
01/30/2025 E (F 639 )
A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. (F 639 ) and/or; The facility develops and implements comprehensive person-centered care plans for each resident that include measurable objectives and time frames to meet each resident's medical, nursing and mental and psychosocial needs which describe services to be furnished to attain or maintain residents highest practical well-being and assess resident or resident representative goals for desired outcomes. (F 656 )
Deficiency #4
02/01/2024 E (F 686 )
The facility ensures residents receive care to prevent pressure ulcers unless resident's clinical condition demonstrates that they were unavoidable and residents with pressure ulcers receive treatment and services to promote healing, prevent infection and prevent new ulcers from developing. (F 686 )
Deficiency #5
02/01/2024 E (F 759 )
The facility ensures that its medication error rates are not 5 percent or greater. (F 759 )

RESIDENT RIGHTS

RESULTS
Standard Survey - 25 of 27 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 24

This nursing facility met 25 out of the 27 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 24. The statewide average facility score was 24.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
02/01/2024 D (F 583)
The facility observes resident rights to personal privacy, including personal and medical records, accommodations, medical treatment, all communications, deliveries, personal care, visits, and meetings of family and resident groups and respects residents? right to refuse the release of personal and medical records when allowed by state and federal law. (F 583) and/or; The facility maintains medical records containing required information on each resident that are complete, accurately documented, readily accessible and Systematically organized; ensures all identifiable resident records remain confidential and does not release identifiable resident information unless permitted to do so; safeguards medical record information against loss, destruction, or unauthorized use; and retains the medical records for the specified amount of time. ( F 842)
Deficiency #2
01/30/2025 D (F 550 )
The facility treats each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident?s individuality; provide equal access to quality care regardless of diagnosis, severity of condition, or payment source; and ensures that residents can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. (F 550 )

KITCHEN/FOOD SERVICES

RESULTS
Standard Survey - 11 of 12 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 11

This nursing facility met 11 out of the 12 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 11. The statewide average facility score was 11.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
12/22/2022 D (F 812 )
The facility procures food from sources approved or considered satisfactory by federal state or local authorities and stores, prepares, distributes and serves food in accordance with professional standards for food service safety. (F 812 ) and/or; The facility has a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. (F 813 )

ENVIRONMENT

RESULTS
Standard Survey - 20 of 21 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 18

This nursing facility met 20 out of the 21 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 18. The statewide average facility score was 18.