Deficiency Records for Little Brook Nursing and Convalescent Home
Updated as of March 01, 2024
A list of the most recent deficiencies for Little Brook Nursing and Convalescent Home. 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? |
|---|---|---|---|---|
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2023-06-15 | 2023-08-21 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-06-15 | 2023-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-15 | 2023-08-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-15 | 2023-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-15 | 2023-07-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-15 | 2023-07-26 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-06-15 | 2023-07-26 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-06-15 | 2023-07-26 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2023-06-15 | 2023-07-26 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-15 | 2023-07-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-15 | 2023-07-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-15 | 2023-07-25 | N |
| 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 | 2023-06-15 | 2023-07-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-15 | 2023-07-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-15 | 2023-07-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-15 | 2023-07-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-15 | 2023-07-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-15 | 2023-07-25 | 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 | 2023-06-15 | 2023-07-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-15 | 2023-07-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-15 | 2023-07-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-06-15 | 2023-07-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-07-25 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-15 | 2023-07-25 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-15 | 2023-07-25 | 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 | 2023-06-15 | 2023-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-15 | 2023-07-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-15 | 2023-07-25 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-06-15 | 2023-07-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-13 | 2022-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-13 | 2022-10-13 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-13 | 2022-10-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-23 | 2022-04-05 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-21 | 2021-11-15 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2021-05-21 | 2021-09-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-21 | 2021-07-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-21 | 2021-06-22 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-21 | 2021-06-12 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-05-21 | 2021-06-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-21 | 2021-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-21 | 2021-06-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-21 | 2021-06-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-21 | 2021-06-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-21 | 2021-06-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-21 | 2021-06-08 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-05-21 | 2021-06-08 | 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 | 2021-05-21 | 2021-06-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-05-21 | 2021-06-07 | 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 | 2021-05-21 | 2021-06-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-21 | 2021-06-06 | 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 | 2021-05-21 | 2021-06-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-21 | 2021-06-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-21 | 2021-05-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-21 | 2021-05-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-05-21 | 2021-05-24 | N |
| Post nurse staffing information every day. | Health | 2021-05-21 | 2021-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-21 | 2021-05-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-21 | 2021-05-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-02 | 2019-09-12 | 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 | 2019-08-02 | 2019-09-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-08-02 | 2019-09-12 | N |
