A list of the most recent deficiencies for Brewster Health 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-07 | 2023-12-07 | 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 | 2023-11-07 | 2023-12-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-09 | 2023-10-30 | 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 | 2023-10-09 | 2023-10-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-09 | 2023-10-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-09 | 2023-10-30 | Y |
| Post nurse staffing information every day. | Health | 2023-10-09 | 2023-10-30 | 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 | 2023-10-09 | 2023-10-30 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-09 | 2023-10-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-21 | 2022-05-27 | 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 | 2022-04-21 | 2022-05-27 | 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 | 2022-04-21 | 2022-05-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-21 | 2022-05-27 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-05 | 2021-05-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-25 | 2021-04-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-25 | 2021-04-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-25 | 2021-04-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-25 | 2021-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-25 | 2021-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-25 | 2021-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-25 | 2021-04-14 | N |
