Deficiency Records for Thatcher Brook Rehabilitation and Care Center

A list of the most recent deficiencies for Thatcher Brook Rehabilitation and Care 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?
Have generator or other power source capable of supplying service within 10 seconds.	Fire Safety	2023-09-28	2023-10-26	N
Develop and maintain an Emergency Preparedness Program (EP).	Fire Safety	2023-09-28	2023-10-19	N
Keep aisles, corridors, and exits free of obstruction in case of emergency.	Fire Safety	2023-09-28	2023-10-19	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	2023-09-28	2023-10-19	N
Install smoke barrier doors that can resist smoke for at least 20 minutes.	Fire Safety	2023-09-28	2023-10-19	N
Ensure proper usage of power strips and extension cords.	Fire Safety	2023-09-28	2023-10-19	N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	Health	2022-06-23	2022-08-01	N
Provide safe and appropriate respiratory care for a resident when needed.	Health	2022-06-23	2022-08-01	N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	Health	2022-06-23	2022-08-01	N
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.	Health	2022-06-23	2022-08-01	N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Health	2022-06-23	2022-08-01	N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	Health	2022-06-23	2022-08-01	N
Provide and implement an infection prevention and control program.	Health	2022-06-23	2022-08-01	N
Implement a program that monitors antibiotic use.	Health	2022-06-23	2022-08-01	N
Perform COVID19 testing on residents and staff.	Health	2022-06-23	2022-08-01	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	2022-06-23	2022-08-01	N
Develop and maintain an Emergency Preparedness Program (EP).	Fire Safety	2022-06-22	2022-08-01	N
Have simulated fire drills held at unexpected times.	Fire Safety	2022-06-22	2022-08-01	N
Allow residents to self-administer drugs if determined clinically appropriate.	Health	2019-12-19	2020-01-31	N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	Health	2019-12-19	2020-01-31	N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	Health	2019-12-19	2020-01-31	N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	Health	2019-12-19	2020-01-31	N
Provide appropriate treatment and care according to orders, resident?s preferences and goals.	Health	2019-12-19	2020-01-31	N
Provide safe, appropriate pain management for a resident who requires such services.	Health	2019-12-19	2020-01-31	N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	Health	2019-12-19	2020-01-31	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	2019-12-19	2020-01-31	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	2019-12-19	2020-01-31	N
Ensure medication error rates are not 5 percent or greater.	Health	2019-12-19	2020-01-31	N
Ensure that residents are free from significant medication errors.	Health	2019-12-19	2020-01-31	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	2019-12-19	2020-01-31	N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.	Health	2019-12-19	2020-01-31	N
Keep complete, dated laboratory records in the resident's record.	Health	2019-12-19	2020-01-31	N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	Health	2019-12-19	2020-01-31	N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Health	2019-12-19	2020-01-31	N
Provide and implement an infection prevention and control program.	Health	2019-12-19	2020-01-31	N
Implement a program that monitors antibiotic use.	Health	2019-12-19	2020-01-31	N
Keep aisles, corridors, and exits free of obstruction in case of emergency.	Fire Safety	2019-12-19	2020-01-22	N

Deficiency Records for Thatcher Brook Rehabilitation and Care Center

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