Deficiency Records for Brookdale Healthcare and Wellness Centre, LP
Updated as of March 01, 2024
A list of the most recent deficiencies for Brookdale Healthcare and Wellness Centre, LP. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-10 | 2023-11-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-10 | 2023-11-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-28 | 2023-10-20 | 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 | 2023-08-28 | 2023-10-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-08-28 | 2023-10-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-24 | 2023-09-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-24 | 2023-09-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-24 | 2023-09-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-24 | 2023-09-24 | 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 | 2023-08-24 | 2023-09-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-24 | 2023-09-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-08-28 | 2023-08-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-21 | 2023-04-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-04-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-13 | 2022-05-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-13 | 2022-05-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-14 | 2022-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-30 | 2022-03-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-10-11 | 2021-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-04 | 2021-08-23 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-21 | 2021-08-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Establish methods for sharing information. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-01-16 | 2020-02-04 | 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 | 2020-01-16 | 2020-02-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-15 | 2019-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-15 | 2019-12-15 | 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 | 2019-11-15 | 2019-12-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-15 | 2019-12-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-15 | 2019-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-15 | 2019-12-15 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-17 | 2019-02-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-17 | 2019-02-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-17 | 2019-02-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-17 | 2019-02-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-17 | 2019-02-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-17 | 2019-02-17 | N |
