Deficiency Records for Blue Hills Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Blue Hills Health 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-31 | 2023-08-31 | 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 | 2023-07-31 | 2023-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-24 | 2023-08-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-24 | 2023-08-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-24 | 2023-08-23 | 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 | 2023-07-24 | 2023-08-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-07-24 | 2023-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-24 | 2023-08-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-07-24 | 2023-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-07-24 | 2023-08-23 | 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 | 2023-07-24 | 2023-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-24 | 2023-08-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-07-24 | 2023-08-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-09 | 2022-03-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-09 | 2022-03-18 | N |
| Respond appropriately to all alleged violations. | Health | 2022-02-09 | 2022-03-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-09 | 2022-03-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-09 | 2022-03-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-09 | 2022-03-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-09 | 2022-03-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-09 | 2022-03-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-09 | 2022-03-18 | 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 | 2022-02-09 | 2022-03-18 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-09 | 2022-03-18 | N |
| 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. | Health | 2022-02-09 | 2022-03-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-09 | 2022-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-03-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-09 | 2022-03-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-15 | 2022-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-15 | 2022-03-02 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-02-15 | 2022-03-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-15 | 2022-03-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-15 | 2022-03-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-15 | 2022-03-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-15 | 2022-02-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-15 | 2022-02-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-15 | 2022-02-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-15 | 2022-02-15 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-06-20 | 2019-08-16 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-06-20 | 2019-08-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-20 | 2019-08-16 | 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 | 2019-06-20 | 2019-08-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-20 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-20 | 2019-08-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-20 | 2019-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-20 | 2019-08-16 | 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 | 2019-06-20 | 2019-08-16 | 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 | 2019-06-20 | 2019-08-16 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-06-20 | 2019-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-20 | 2019-08-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-25 | 2019-08-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-25 | 2019-08-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-25 | 2019-08-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-25 | 2019-07-12 | N |
