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Deficiency Records for Brookside Care Strategies
A list of the most recent deficiencies for Brookside Care Strategies. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Brookside Care Strategies. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-01-08 | 2025-01-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-23 | 2024-10-29 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-08-23 | 2024-10-29 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-08-23 | 2024-10-29 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-09-26 | 2024-10-29 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-09-26 | 2024-10-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-09-26 | 2024-10-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-26 | 2024-10-29 | N |
| Post nurse staffing information every day. | Health | 2024-09-26 | 2024-10-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-09-26 | 2024-10-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-26 | 2024-10-29 | 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 | 2024-09-26 | 2024-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-26 | 2024-10-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-09-26 | 2024-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-26 | 2024-10-29 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2024-09-26 | 2024-10-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-09-26 | 2024-10-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-26 | 2024-10-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-26 | 2024-10-29 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2024-10-07 | 2024-10-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-24 | 2024-07-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-23 | 2024-03-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-23 | 2024-03-15 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-02-23 | 2024-03-15 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-11-27 | 2024-01-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-17 | 2023-12-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-11-17 | 2023-12-28 | 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 | 2023-11-17 | 2023-12-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-17 | 2023-12-28 | 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 | 2023-11-17 | 2023-12-28 | N |
| Keep all essential equipment working safely. | Health | 2023-11-17 | 2023-12-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-11-17 | 2023-12-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-30 | 2023-10-27 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-30 | 2023-10-27 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-08-30 | 2023-10-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-09 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-09 | 2023-09-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-12 | 2023-07-10 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-12 | 2023-07-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-30 | 2023-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-30 | 2023-05-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-30 | 2023-05-05 | 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 | 2023-03-14 | 2023-05-05 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-14 | 2023-05-05 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-02-27 | 2023-05-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-27 | 2023-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-27 | 2023-05-05 | 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 | 2023-01-27 | 2023-05-05 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-27 | 2023-05-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-15 | 2023-05-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-15 | 2023-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-15 | 2023-05-05 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-15 | 2023-05-05 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-24 | 2022-12-19 | 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 | 2022-10-24 | 2022-12-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-24 | 2022-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-24 | 2022-12-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-24 | 2022-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-24 | 2022-12-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-24 | 2022-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-24 | 2022-12-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-11-07 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-23 | 2022-11-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-23 | 2022-11-07 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-20 | 2022-06-09 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-20 | 2022-06-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-06 | 2022-05-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-06 | 2022-05-23 | Y |
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