Deficiency Records for The Brook at High Falls Nursing Home and Rehab Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for The Brook at High Falls Nursing Home and Rehab 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? |
|---|---|---|---|---|
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-10 | 2023-06-30 | 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 | 2023-05-10 | 2023-06-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-10 | 2023-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-06-23 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-10 | 2023-06-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-10 | 2023-06-23 | 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 | 2023-05-10 | 2023-06-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-10 | 2023-06-23 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-10 | 2023-06-23 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-10 | 2023-06-23 | 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 | 2023-05-10 | 2023-06-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-10 | 2023-06-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-10 | 2023-06-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-23 | 2022-01-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-11-23 | 2022-01-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-23 | 2022-01-14 | 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 | 2021-11-23 | 2022-01-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-05-07 | 2019-06-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-07 | 2019-06-27 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-05-07 | 2019-06-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-07 | 2019-06-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-07 | 2019-06-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-07 | 2019-06-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-07 | 2019-06-05 | N |
