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Deficiency Records for Pleasant Bay of Brewster Rehab Center
A list of the most recent deficiencies for Pleasant Bay of Brewster Rehab Center. 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 Pleasant Bay of Brewster Rehab Center. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-24 | 2024-08-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-24 | 2024-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-21 | 2024-06-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-19 | 2024-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-19 | 2024-05-26 | 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 | 2024-03-19 | 2024-05-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-19 | 2024-04-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-19 | 2024-04-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-03-19 | 2024-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-19 | 2024-04-26 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-19 | 2024-04-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-19 | 2024-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-19 | 2024-04-26 | 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 | 2024-03-19 | 2024-04-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-19 | 2024-04-26 | 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 | 2024-03-19 | 2024-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-19 | 2024-04-26 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-03-19 | 2024-04-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Develop a communication plan. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-20 | 2024-04-25 | 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 | 2024-03-20 | 2024-04-25 | 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 | 2024-03-20 | 2024-04-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-20 | 2024-04-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-19 | 2024-04-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-19 | 2024-04-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-19 | 2024-04-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-19 | 2024-04-24 | 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 | 2024-03-19 | 2024-04-24 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-03-19 | 2024-04-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-19 | 2024-04-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-19 | 2024-04-24 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-19 | 2024-04-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-03-19 | 2024-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-19 | 2024-04-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-19 | 2024-04-24 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-03-19 | 2024-04-24 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-03-19 | 2024-04-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-20 | 2023-10-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-20 | 2023-10-16 | Y |
| 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 | 2023-09-20 | 2023-10-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-20 | 2023-10-16 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-03 | 2023-02-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-03 | 2023-02-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-03 | 2023-02-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-24 | 2022-10-14 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-08-24 | 2022-10-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-24 | 2022-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-24 | 2022-10-14 | 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 | 2022-08-24 | 2022-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-24 | 2022-10-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-24 | 2022-10-14 | 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 | 2022-08-24 | 2022-10-14 | 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 | 2022-08-24 | 2022-10-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-08-24 | 2022-10-14 | N |
| 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 | 2022-08-24 | 2022-10-14 | 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 | 2022-08-24 | 2022-10-14 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-08-24 | 2022-10-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-24 | 2022-10-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-24 | 2022-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-24 | 2022-10-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-08-24 | 2022-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-24 | 2022-10-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-29 | 2022-10-13 | 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 | 2022-08-29 | 2022-10-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-29 | 2022-10-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-24 | 2022-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-10-06 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-24 | 2022-10-06 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-24 | 2022-10-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-24 | 2022-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-24 | 2022-09-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-05 | 2022-04-28 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-04-05 | 2022-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-11-12 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-27 | 2021-11-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-13 | 2019-09-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-13 | 2019-09-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-13 | 2019-09-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-13 | 2019-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-13 | 2019-09-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-11 | 2019-08-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-11 | 2019-08-23 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-07-11 | 2019-08-23 | N |
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