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Deficiency Records for Emerald Nursing and Rehab Brookside LLC
A list of the most recent deficiencies for Emerald Nursing and Rehab Brookside LLC. 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 Emerald Nursing and Rehab Brookside LLC. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-22 | 2024-10-01 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-08-22 | 2024-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-22 | 2024-10-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-08-22 | 2024-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-22 | 2024-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-22 | 2024-10-01 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-08-22 | 2024-10-01 | Y |
| 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 | 2024-08-22 | 2024-10-01 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-08-22 | 2024-10-01 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-08-22 | 2024-10-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Use approved construction type or materials. | Fire Safety | 2024-08-21 | 2024-10-01 | 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 | 2024-08-21 | 2024-10-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-08-21 | 2024-10-01 | 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 | 2024-08-21 | 2024-10-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-08-21 | 2024-10-01 | N |
| 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 | 2024-07-24 | 2024-08-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-09 | 2024-05-24 | 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 | 2024-04-09 | 2024-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-09 | 2024-05-24 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-06 | 2024-03-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-03-22 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-02-06 | 2024-03-22 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-25 | 2024-02-01 | 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 | 2023-09-25 | 2024-02-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-25 | 2024-02-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-09-25 | 2023-12-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-25 | 2023-12-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-25 | 2023-12-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-26 | 2023-11-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-26 | 2023-11-10 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-26 | 2023-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-26 | 2023-11-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-09-26 | 2023-11-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-26 | 2023-11-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-26 | 2023-11-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-26 | 2023-11-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-26 | 2023-11-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-26 | 2023-11-10 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-26 | 2023-11-10 | 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 | 2023-09-25 | 2023-11-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-09-25 | 2023-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-01 | 2023-07-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-01 | 2023-06-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-20 | 2023-04-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-20 | 2023-04-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-20 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-20 | 2023-04-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-20 | 2023-01-25 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-12-20 | 2023-01-25 | Y |
| 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 | 2022-12-20 | 2023-01-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-20 | 2023-01-25 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-29 | 2022-11-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-29 | 2022-11-13 | 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 | 2022-09-29 | 2022-11-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-29 | 2022-10-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-29 | 2022-10-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-09-29 | 2022-10-23 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-29 | 2022-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-10-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-29 | 2022-10-23 | N |
| Post nurse staffing information every day. | Health | 2022-09-29 | 2022-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-29 | 2022-10-23 | N |
| Provide activities to meet all resident's needs. | Health | 2022-09-29 | 2022-10-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-29 | 2022-10-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-29 | 2022-10-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-29 | 2022-10-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-10-23 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-29 | 2022-10-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-11 | 2022-09-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-21 | 2022-07-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-21 | 2022-07-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-21 | 2022-07-24 | 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 | 2022-05-10 | 2022-06-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-20 | 2022-02-23 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-20 | 2022-02-23 | Y |
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