Brandon Woods of New Bedford

In the surveyor’s words

From the most serious findings on record at Brandon Woods of New Bedford, in the surveyor’s own words.

• Immediate jeopardy, patternF600Dec 16, 2024

  Based on observation, record review, and interviews, the facility failed to provide a safe environment free from physical abuse, sexual abuse, and neglect for one Resident (#77), from a total sample of 23 residents. Specifically, the facility failed to ensure Resident #77, with severe cognitive impairment and a history of aggression, violence, and sexually inappropriate behaviors toward staff and other residents, did not physically and sexually abuse other residents; and that Resident #77 was protected from being physically abused by other residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused. […]

• Immediate jeopardy, patternF740Dec 16, 2024

  Based on observation, record review, and interview, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#77), with a known history of conduct disorder, dementia with behavioral disturbance, and major depression, out of a total sample of 23 residents. Specifically, the facility failed to develop, implement, and update the plan of care to meet the Resident's behavioral needs, resulting in wandering intrusively into other residents' rooms; standing at female residents' bedsides and fondling his/her genitals; exposing him/herself to another resident; physically assaulting and being physically assaulted by other residents. […]

• Immediate jeopardy, patternF741Dec 16, 2024

  Based on record reviews and interviews, for one Resident (#77), out of a total sample of 23 residents, the facility failed to provide appropriate and sufficient staff to provide behavioral health care services as indicated in the facility assessment. Specifically, for Resident #77 with a known history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, physically abusing other residents, being physically abused by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents, the facility failed to ensure staff had appropriate competencies and skill sets to effectively manage his/her behavioral health needs, including developing non-pharmacological interventions. […]

• Actual harm, patternF607Dec 16, 2024

  Based on interviews and record review, the facility failed to implement their abuse policy for one Resident (#77), out of a sample of 23 residents. Specifically, the facility failed to ensure nursing staff notified the Director of Nurses (DON) and Administrator about allegations of physical and sexual abuse; keep residents safe by implementing protective measures to prevent further abuse by Resident #77; keep Resident #77 safe by implementing protective measures to prevent further physical abuse by other residents; report and investigate abuse allegations as required; report allegations to the state agency (SA) and law enforcement; and ensure all staff received required abuse training. […]

• Actual harm, patternF609Dec 16, 2024

  Based on interviews and record review, the facility failed to report allegations of abuse and neglect for one Resident (#77), out of a sample of 23 residents. Specifically, the facility failed to report five of five allegations of physical abuse, sexual abuse, and neglect to the state agency (SA) and two of five allegations to law enforcement as required. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually harassed and exposed to another person's genitals. […]