A list of the most recent deficiencies for Breezy Hills Rehab 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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-08 | 2023-03-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-08 | 2023-03-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-08 | 2023-03-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-08 | 2023-03-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-08 | 2023-03-10 | 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 | 2023-02-08 | 2023-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-08 | 2023-03-10 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-02-08 | 2023-03-10 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-02-08 | 2023-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-03-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-08 | 2023-03-10 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-27 | 2021-08-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-05-27 | 2021-08-26 | 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 | 2021-05-27 | 2021-08-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-27 | 2021-08-26 | N |
| 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 | 2021-05-27 | 2021-06-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-27 | 2021-06-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-27 | 2021-06-27 | 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 | 2021-05-27 | 2021-06-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Develop a communication plan. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Have enough space near smoke barriers to protect residents. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-25 | 2021-06-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-09 | 2019-09-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-07 | 2019-09-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-07 | 2019-09-09 | N |
