Inspection visit
Inspection
Citations
32 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0018GeneralS&S Cno actual harm
Establish procedures for tracking staff and patients during an emergency.
- 0022GeneralS&S Cno actual harm
Establish policies and procedures for sheltering.
- 0026GeneralS&S Cno actual harm
Establish roles under a Waiver declared by secretary.
- 0031GeneralS&S Cno actual harm
Provide emergency officials' contact information.
- 0161GeneralS&S Epotential for harm
Use approved construction type or materials.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F711 - Physician Visits
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F849 - Hospice services
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.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- 0886GeneralS&S Fpotential for harm
Perform COVID19 testing on residents and staff.
- 0041GeneralS&S Cno actual harm
Implement emergency and standby power systems.
FAQ · About this visit
Common questions about this visit
What happened during the March 2, 2023 survey of MILL BROOK REHABILITATION AND HEALTHCARE CENTER?
This was a inspection survey of MILL BROOK REHABILITATION AND HEALTHCARE CENTER on March 2, 2023. The surveyor cited 32 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MILL BROOK REHABILITATION AND HEALTHCARE CENTER on March 2, 2023?
Yes, 32 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.