Deficiency Records for Brookhaven Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Brookhaven Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-16 | 2022-03-18 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-09-02 | 2021-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-02 | 2021-11-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-31 | 2021-11-11 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2021-08-31 | 2021-11-11 | 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 | 2019-11-21 | 2020-01-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-21 | 2020-01-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-21 | 2020-01-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-21 | 2020-01-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-21 | 2020-01-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-21 | 2020-01-03 | 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 | 2019-11-21 | 2020-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2020-01-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-21 | 2020-01-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-19 | 2020-01-03 | 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 | 2018-09-20 | 2018-11-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-20 | 2018-11-05 | 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 | 2018-09-20 | 2018-11-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-20 | 2018-11-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-09-20 | 2018-11-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-20 | 2018-11-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-09-20 | 2018-11-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-20 | 2018-11-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-09-20 | 2018-11-05 | 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 | 2018-09-20 | 2018-11-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-09-20 | 2018-11-05 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-09-20 | 2018-11-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-09-20 | 2018-11-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-20 | 2018-11-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-09-20 | 2018-11-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-20 | 2018-11-05 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-09-20 | 2018-11-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-20 | 2018-11-05 | N |
