A list of the most recent deficiencies for Brooke Grove Rehab. and Nsg Ctr. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-02-28 | 2020-03-27 | 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 | 2020-02-28 | 2020-03-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-28 | 2020-03-27 | 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 | 2020-02-28 | 2020-03-27 | 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 | 2020-02-28 | 2020-03-27 | 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 | 2020-02-28 | 2020-03-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-02-28 | 2020-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-28 | 2020-03-27 | 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 | 2020-03-02 | 2020-03-03 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-02-15 | 2019-03-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-15 | 2019-03-20 | 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 | 2019-02-15 | 2019-03-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-15 | 2019-03-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-15 | 2019-03-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-15 | 2019-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-15 | 2019-03-20 | 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 | 2019-02-15 | 2019-03-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-15 | 2019-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-15 | 2019-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-15 | 2019-03-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-15 | 2019-03-20 | 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 | 2019-02-15 | 2019-03-20 | 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 | 2019-02-15 | 2019-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-15 | 2019-03-20 | 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 | 2019-02-21 | 2019-03-20 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-02-21 | 2019-03-20 | 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 | 2018-01-16 | 2018-02-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-01-16 | 2018-02-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-01-16 | 2018-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-16 | 2018-02-23 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-01-10 | 2018-02-19 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-01-10 | 2018-02-19 | 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 | 2018-01-10 | 2018-02-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-10 | 2018-02-19 | 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 | 2018-01-10 | 2018-02-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-01-10 | 2018-02-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-10 | 2018-02-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-10 | 2018-02-19 | 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 | 2018-01-10 | 2018-02-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-01-10 | 2018-02-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-10 | 2018-02-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-10 | 2018-02-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-10 | 2018-01-10 | N |
