Deficiency Records for Brookmont Healthcare and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Brookmont Healthcare 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-05 | 2023-06-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-05 | 2023-06-27 | 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 | 2023-05-05 | 2023-06-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-05 | 2023-06-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-05 | 2023-06-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-05 | 2023-06-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-05 | 2023-06-27 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-05 | 2023-06-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-05 | 2023-06-27 | 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 | 2023-05-05 | 2023-06-27 | 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 | 2023-05-05 | 2023-06-27 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-05-05 | 2023-06-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-05 | 2023-06-27 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-05-05 | 2023-06-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-05 | 2023-06-27 | Y |
| 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 | 2023-05-05 | 2023-06-27 | Y |
| 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 | 2023-05-10 | 2023-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-10 | 2023-06-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-10 | 2023-06-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-27 | 2023-02-16 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-01-27 | 2023-02-16 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-27 | 2023-02-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-24 | 2022-09-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-24 | 2022-08-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-24 | 2022-08-24 | 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 | 2022-06-24 | 2022-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-24 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-24 | 2022-08-24 | N |
| Report COVID19 data to residents and families. | Health | 2022-06-24 | 2022-08-24 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-24 | 2022-08-24 | 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 | 2022-06-24 | 2022-08-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-24 | 2022-08-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-21 | 2022-08-02 | 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 | 2022-06-21 | 2022-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-21 | 2022-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-21 | 2022-08-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-27 | 2021-09-15 | 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 | 2021-07-27 | 2021-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-27 | 2021-09-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-27 | 2021-09-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-27 | 2021-09-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-27 | 2021-09-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-27 | 2021-09-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-23 | 2021-09-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-23 | 2021-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-23 | 2021-09-09 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-23 | 2021-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-09-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-07-23 | 2021-09-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-08 | Not Fixed | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-11-08 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | Not Fixed | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-11-08 | Not Fixed | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-06-27 | Not Fixed | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-06-27 | Not Fixed | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-27 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-27 | Not Fixed | Y |
