A list of the most recent deficiencies for The Lodge at Brookline. 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? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-20 | 2024-02-09 | 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 | 2023-12-20 | 2024-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-20 | 2023-12-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-03 | 2023-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-03 | 2023-09-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-03 | 2023-09-20 | 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 | 2023-08-03 | 2023-09-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-03 | 2023-09-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-03 | 2023-09-20 | 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 | 2023-08-03 | 2023-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-03 | 2023-09-20 | 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 | 2023-02-08 | 2023-02-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-08 | 2023-02-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-20 | 2022-12-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-20 | 2022-12-30 | 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 | 2022-07-26 | 2022-08-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-26 | 2022-08-18 | 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 | 2022-03-10 | 2022-04-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-03-10 | 2022-04-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-10 | 2022-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-10 | 2022-04-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-10 | 2022-04-15 | 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 | 2022-03-10 | 2022-04-15 | 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 | 2022-03-10 | 2022-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-10 | 2022-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-10 | 2022-04-15 | 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 | 2022-03-10 | 2022-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-10 | 2022-04-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-10 | 2022-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-10 | 2022-04-15 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-03-10 | 2022-03-10 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-31 | 2019-10-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-31 | 2019-10-31 | 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 | 2019-07-31 | 2019-10-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-31 | 2019-10-25 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-07-31 | 2019-10-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-31 | 2019-10-25 | N |
| Have an externally vented heating system. | Fire Safety | 2019-07-31 | 2019-10-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-01 | 2019-09-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-01 | 2019-09-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-08-01 | 2019-09-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-01 | 2019-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-01 | 2019-09-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-08-01 | 2019-09-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-01 | 2019-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-01 | 2019-09-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-01 | 2019-09-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-31 | 2019-09-04 | 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 | 2019-07-31 | 2019-08-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-07-31 | 2019-08-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-31 | 2019-08-01 | N |
