A list of the most recent deficiencies for Brookwood Retirement Community. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Use approved construction type or materials. | Fire Safety | 2023-10-26 | 2023-12-01 | 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 | 2023-10-26 | 2023-12-01 | 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 | 2023-10-26 | 2023-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-26 | 2023-12-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-26 | 2023-11-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-26 | 2023-11-24 | 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 | 2023-10-26 | 2023-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-11-24 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-10-26 | 2023-11-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-29 | 2021-10-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-29 | 2021-10-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-29 | 2021-10-22 | 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 | 2021-09-29 | 2021-10-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-10 | 2021-07-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-07-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-31 | 2019-12-16 | 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 | 2019-10-31 | 2019-12-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-31 | 2019-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-12-16 | 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 | 2019-10-31 | 2019-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-31 | 2019-12-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-31 | 2019-12-16 | N |
| Provide appropriate foot care. | Health | 2019-10-31 | 2019-12-16 | 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 | 2019-10-31 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-31 | 2019-12-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-31 | 2019-12-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-31 | 2019-12-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-31 | 2019-12-16 | 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 | 2019-10-31 | 2019-12-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-10-31 | 2019-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-12-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-28 | 2019-12-16 | 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 | 2019-10-28 | 2019-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-28 | 2019-12-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-28 | 2019-12-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-28 | 2019-12-16 | N |
| Post nurse staffing information every day. | Health | 2019-10-31 | 2019-12-02 | 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 | 2018-09-20 | 2018-10-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-20 | 2018-10-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-20 | 2018-10-16 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-20 | 2018-10-16 | 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 | 2018-10-16 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-20 | 2018-10-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-20 | 2018-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-20 | 2018-10-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-20 | 2018-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-20 | 2018-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-20 | 2018-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-24 | 2018-10-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-24 | 2018-10-16 | N |
