Deficiency Records for Emerald Nursing and Rehab Brookside LLC
Updated as of May 01, 2020
This is not the most recent data for Emerald Nursing and Rehab Brookside LLC. For the most recent information, click here.
A list of the most recent deficiencies for Emerald Nursing and Rehab Brookside LLC. 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 | 2019-09-30 | 2019-11-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-30 | 2019-11-11 | 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 | 2019-09-30 | 2019-11-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-30 | 2019-11-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-30 | 2019-11-11 | 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 ne | Health | 2019-09-30 | 2019-11-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-30 | 2019-11-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-09-30 | 2019-11-11 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-30 | 2019-11-11 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-30 | 2019-11-11 | Y |
| 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 | 2019-09-30 | 2019-11-11 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-09-30 | 2019-11-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-09-30 | 2019-11-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-27 | 2019-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-27 | 2019-11-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-09-30 | 2019-11-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-30 | 2019-11-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-30 | 2019-11-08 | Y |
| 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 | 2019-09-30 | 2019-11-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-09-30 | 2019-11-08 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-30 | 2019-11-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-30 | 2019-11-04 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-30 | 2019-11-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-06-13 | 2018-07-28 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Be properly staffed | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-05-21 | 2018-07-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-21 | 2018-07-06 | 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 | 2018-05-22 | 2018-07-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-05-22 | 2018-07-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-22 | 2018-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-22 | 2018-07-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-22 | 2018-07-06 | 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 ne | Health | 2018-05-22 | 2018-07-06 | N |
| Provide or obtain dental services for each resident. | Health | 2018-05-22 | 2018-07-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-05-22 | 2018-07-06 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2018-05-22 | 2018-07-06 | 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 | 2018-05-22 | 2018-07-06 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-05-22 | 2018-07-06 | Y |
| Meet other general requirements. | Fire Safety | 2017-05-18 | 2017-07-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-05-18 | 2017-07-09 | 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 | 2017-05-18 | 2017-07-09 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2017-05-18 | 2017-07-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-05-18 | 2017-07-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-05-18 | 2017-07-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-05-18 | 2017-07-09 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-05-25 | 2017-06-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-05-25 | 2017-06-16 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-05-25 | 2017-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-25 | 2017-06-16 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-05-25 | 2017-06-16 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-05-25 | 2017-06-16 | N |
| Provide housekeeping and maintenance services. | Health | 2017-05-25 | 2017-06-16 | Y |
| Maintain comfortable sound levels. | Health | 2017-05-25 | 2017-06-16 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-05-25 | 2017-06-16 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-25 | 2017-06-16 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2017-05-04 | 2017-06-01 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-05-04 | 2017-06-01 | Y |
