Deficiency Records for Brewster Health Center

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Updated as of April 01, 2024

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