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Deficiency Records for Brookside Rehab and Nursing Center
A list of the most recent deficiencies for Brookside Rehab and Nursing 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 Brookside Rehab and Nursing 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-01 | 2023-10-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-01 | 2023-10-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-01 | 2023-10-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-01 | 2023-10-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-01 | 2023-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-01 | 2023-10-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-01 | 2023-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-01 | 2023-10-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-01 | 2023-10-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-01 | 2023-10-16 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-09-01 | 2023-10-16 | N |
| Post nurse staffing information every day. | Health | 2023-09-01 | 2023-10-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-01 | 2023-10-16 | 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 | 2023-09-01 | 2023-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-01 | 2023-10-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-09-01 | 2023-10-16 | 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 | 2023-09-01 | 2023-10-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-01 | 2023-10-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-01 | 2023-10-16 | 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 | 2023-09-01 | 2023-10-16 | 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 | 2023-09-01 | 2023-10-16 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-01 | 2023-10-16 | 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 | 2023-09-01 | 2023-10-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-01 | 2023-10-16 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-01 | 2023-10-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-01 | 2023-10-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-01 | 2023-10-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-01 | 2023-10-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-01 | 2023-10-16 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-09-07 | 2023-09-18 | N |
| Meet other general requirements. | Fire Safety | 2022-02-22 | 2023-09-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-22 | 2023-09-18 | 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 | 2022-02-22 | 2023-09-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-22 | 2023-09-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-22 | 2023-09-18 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2022-02-22 | 2022-04-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-22 | 2022-04-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-22 | 2022-04-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-02-22 | 2022-04-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-22 | 2022-04-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-22 | 2022-04-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-22 | 2022-04-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-17 | 2022-03-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-17 | 2022-03-23 | N |
| 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 | 2022-02-17 | 2022-03-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-17 | 2022-03-23 | 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 | 2022-02-17 | 2022-03-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-17 | 2022-03-23 | 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 | 2022-02-17 | 2022-03-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-17 | 2022-03-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-17 | 2022-03-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-17 | 2022-03-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-17 | 2022-03-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-02-17 | 2022-03-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-17 | 2022-03-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-17 | 2022-03-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-17 | 2022-03-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-17 | 2022-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-17 | 2022-03-23 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-02-17 | 2022-03-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-17 | 2022-03-23 | Y |
| 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 | 2022-02-17 | 2022-03-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-17 | 2022-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-23 | Y |
| Have a combustible roofing system that meets safety standards. | Fire Safety | 2019-11-07 | 2020-03-31 | 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 | 2019-11-07 | 2020-03-31 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-11-07 | 2020-03-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-07 | 2020-03-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-11-07 | 2020-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-07 | 2020-03-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-11-07 | 2020-03-06 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2019-10-10 | 2019-11-08 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-10-10 | 2019-11-08 | N |
| 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 | 2019-10-10 | 2019-11-08 | 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 | 2019-10-10 | 2019-11-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-10 | 2019-11-08 | N |
| 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 | 2019-10-10 | 2019-11-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-10 | 2019-11-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-10 | 2019-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-10 | 2019-11-08 | 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 | 2019-10-10 | 2019-11-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-10 | 2019-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-10 | 2019-11-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-10 | 2019-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-10 | 2019-11-08 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-10 | 2019-11-08 | 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 | 2019-10-10 | 2019-11-08 | 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 | 2019-10-10 | 2019-11-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-10 | 2019-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-08 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-10-10 | 2019-11-08 | N |
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