Deficiency Records for Thatcher Brook Rehabilitation and Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Thatcher Brook Rehabilitation and Care 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-28 | 2023-10-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-28 | 2023-10-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-28 | 2023-10-19 | 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 | 2023-09-28 | 2023-10-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-28 | 2023-10-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-28 | 2023-10-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-23 | 2022-08-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-23 | 2022-08-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-23 | 2022-08-01 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-23 | 2022-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-23 | 2022-08-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-23 | 2022-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-08-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-23 | 2022-08-01 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-23 | 2022-08-01 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-23 | 2022-08-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-22 | 2022-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-22 | 2022-08-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-12-19 | 2020-01-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-19 | 2020-01-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-19 | 2020-01-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-19 | 2020-01-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-19 | 2020-01-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-19 | 2020-01-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-19 | 2020-01-31 | 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 | 2019-12-19 | 2020-01-31 | 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 | 2019-12-19 | 2020-01-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-19 | 2020-01-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-19 | 2020-01-31 | 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 | 2019-12-19 | 2020-01-31 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-12-19 | 2020-01-31 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2019-12-19 | 2020-01-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-19 | 2020-01-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-19 | 2020-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-19 | 2020-01-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-19 | 2020-01-22 | N |
