A list of the most recent deficiencies for Brookshire Post Acute. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-15 | 2024-03-21 | 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 | 2024-02-15 | 2024-02-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-15 | 2024-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-15 | 2024-02-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-15 | 2024-02-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-15 | 2024-02-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-15 | 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 | 2024-01-25 | 2024-02-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-25 | 2024-02-15 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-01-25 | 2024-02-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-25 | 2024-02-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-25 | 2024-02-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-25 | 2024-02-15 | N |
| 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 | 2024-01-25 | 2024-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-01-25 | 2024-02-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-25 | 2024-02-15 | 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 | 2024-01-25 | 2024-02-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-25 | 2024-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-15 | 2024-02-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-12 | 2023-11-22 | 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 | 2023-10-12 | 2023-11-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-12 | 2023-11-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-12 | 2023-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-12 | 2023-11-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-12 | 2023-11-08 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-25 | 2022-11-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-25 | 2022-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-25 | 2022-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-11-08 | 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 | 2022-09-29 | 2022-10-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-29 | 2022-10-04 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2022-09-29 | 2022-10-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-29 | 2022-10-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-09-29 | 2022-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-29 | 2022-10-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-29 | 2022-10-04 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-09-29 | 2022-10-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-29 | 2022-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-10-04 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-29 | 2022-10-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-20 | 2021-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-20 | 2021-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-20 | 2021-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-20 | 2021-08-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-24 | 2021-07-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-07-16 | 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 | 2021-06-24 | 2021-07-16 | N |
