Deficiency Records for Morning Breeze Retirement Community and Healthcare
Updated as of March 01, 2024
A list of the most recent deficiencies for Morning Breeze Retirement Community and Healthcare. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-17 | 2023-08-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-07-17 | 2023-08-10 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-07-17 | 2023-08-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-17 | 2023-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-08-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-17 | 2023-08-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-17 | 2023-08-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-03 | 2023-07-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-03 | 2023-07-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-03 | 2023-07-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-09-26 | 2022-10-21 | N |
| 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 | 2022-09-26 | 2022-10-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-09-26 | 2022-10-21 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-09-26 | 2022-10-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-26 | 2022-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-12 | 2022-09-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-09-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-12 | 2022-09-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-08-12 | 2022-09-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-12 | 2022-09-03 | 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 | 2022-08-12 | 2022-09-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-12 | 2022-09-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-31 | 2022-06-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-13 | 2022-01-28 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-07-21 | 2021-08-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-06-28 | 2021-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-28 | 2021-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-28 | 2021-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-28 | 2021-07-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-28 | 2021-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-28 | 2021-07-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-28 | 2021-07-26 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-06-28 | 2021-07-26 | 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 | 2021-06-28 | 2021-07-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-06-28 | 2021-07-26 | N |
