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Deficiency Records for Brewster Convalescent Center
A list of the most recent deficiencies for Brewster Convalescent 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 Brewster Convalescent 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? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-28 | 2023-11-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-28 | 2023-11-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-28 | 2023-11-02 | 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 | 2023-08-28 | 2023-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-28 | 2023-11-02 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-28 | 2023-11-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-28 | 2023-11-02 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-28 | 2023-11-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-28 | 2023-11-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-28 | 2023-11-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-28 | 2023-11-02 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-08-28 | 2023-11-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-06 | 2023-11-02 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-23 | 2023-11-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-23 | 2023-11-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-23 | 2023-11-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-22 | 2022-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-14 | 2022-03-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-26 | 2021-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-26 | 2021-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-26 | 2021-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-26 | 2021-09-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-26 | 2021-09-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-07-26 | 2021-09-13 | 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 | 2021-07-26 | 2021-09-13 | 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 | 2021-07-26 | 2021-09-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-26 | 2021-09-13 | 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 | 2021-07-26 | 2021-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-26 | 2021-09-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-26 | 2021-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-20 | 2021-09-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-20 | 2021-09-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-20 | 2021-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-20 | 2021-09-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-20 | 2021-09-13 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-06 | 2019-04-08 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-02-07 | 2019-04-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-02-07 | 2019-04-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-02-07 | 2019-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-07 | 2019-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-07 | 2019-04-01 | 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 | 2019-02-06 | 2019-04-01 | 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 | 2019-02-06 | 2019-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-06 | 2019-04-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-06 | 2019-04-01 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-02-06 | Not Fixed | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-06 | Not Fixed | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-02-06 | Not Fixed | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-02-06 | Not Fixed | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-02-06 | Not Fixed | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-06 | Not Fixed | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-02-06 | Not Fixed | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-02-06 | Not Fixed | N |
| Establish methods for sharing information. | Fire Safety | 2019-02-06 | Not Fixed | N |
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