Deficiency Records for Millbrook Healthcare and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Millbrook 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-10 | 2023-02-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-10 | 2023-02-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-20 | 2022-10-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-20 | 2022-10-23 | 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 | 2022-10-19 | 2022-10-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-19 | 2022-10-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-19 | 2022-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-19 | 2022-10-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-20 | 2022-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-02 | 2022-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-08-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-21 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-05-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-09 | 2022-03-06 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-11-03 | 2021-11-30 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-31 | 2021-10-08 | 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 | 2021-09-01 | 2021-09-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-01 | 2021-09-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-31 | 2021-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-28 | 2021-06-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-20 | 2019-07-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-20 | 2019-07-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-06-20 | 2019-07-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-21 | 2019-07-19 | 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 | 2019-06-21 | 2019-07-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-21 | 2019-07-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-21 | 2019-07-19 | N |
| Dispose of garbage and refuse properly. | Health | 2019-06-21 | 2019-07-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-21 | 2019-07-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-06-21 | 2019-07-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-20 | 2019-07-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-20 | 2019-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-20 | 2019-07-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-20 | 2019-06-25 | 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 | 2019-06-20 | 2019-06-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-20 | 2019-06-21 | N |
