Deficiency Records for Breezy Hills Rehab and Care Center
Updated as of January 01, 2019
This is not the most recent data for Breezy Hills Rehab and Care Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-19 | 2018-07-17 | 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 ne | Health | 2018-04-19 | 2018-07-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-19 | 2018-07-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-19 | 2018-07-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
| Be properly staffed | Fire Safety | 2018-04-16 | 2018-05-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-19 | 2018-05-11 | 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 | 2018-04-19 | 2018-05-11 | 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 | 2018-04-19 | 2018-05-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-04 | 2018-03-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-04 | 2018-03-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-04 | 2018-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-03-04 | 2018-03-28 | Y |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-07-31 | 2017-09-06 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-07-31 | 2017-09-06 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-03-28 | 2017-04-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-03-31 | 2017-04-26 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-03-31 | 2017-04-26 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-31 | 2017-04-26 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-31 | 2017-04-26 | N |
| Keep all essential equipment working safely. | Health | 2017-03-31 | 2017-04-26 | N |
| Try to resolve each resident's complaints quickly. | Health | 2016-12-29 | 2017-01-23 | Y |
| Provide timely notification to the resident before transfer or discharge. | Health | 2016-12-29 | 2017-01-23 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-29 | 2017-01-23 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-01-26 | 2016-02-18 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-12-10 | 2016-02-18 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-12-10 | 2016-02-18 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-12-10 | 2016-02-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2015-12-10 | 2016-02-18 | N |
| Keep all essential equipment working safely. | Health | 2015-12-10 | 2016-01-16 | N |
| Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2015-12-10 | 2016-01-10 | N |
| An adequate water supply for the sprinkler system. | Fire Safety | 2015-12-10 | 2016-01-10 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2015-12-10 | 2016-01-10 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2015-12-10 | 2016-01-10 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2015-12-10 | 2016-01-10 | N |
| Try to resolve each resident's complaints quickly. | Health | 2015-12-10 | 2016-01-10 | N |
| Maintain comfortable sound levels. | Health | 2015-12-10 | 2016-01-10 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2015-12-10 | 2016-01-10 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2015-12-10 | 2016-01-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-12-10 | 2016-01-10 | N |
