Breezy Hills Rehab and Care Center

Inspectors wroteBased on observations and interviews, the facility did not follow professional standards for food service safety related to sanitary practices in one of one facility kitchens.

Inspectors wrote2. Review of Resident #68's Level I PASARR dated 3/19/25, showed the resident had diagnoses of anxiety disorder, bipolar disorder, depressive disorder, and mood disorder. The level I PASARR showed the resident did not have validating documentation to support dementia or a related neurocognitive disorder. The review showed Resident #68 had no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASARR evaluation was not submitted for consideration. Review of Resident #68s admission Record revealed the resident was admitted on [DATE] and 9/2/24. The record included the following diagnoses with onset dates: moderate recurrent major depressive disorder (onset 6/14/24), other bipolar disorder (onset 9/2/24), generalized anxiety disorder (onset 9/2/24), and mood disorder due to known physiological condition with depressive features (onset 6/14/24). [...]

Inspectors wroteBased on observations, interviews and record review the facility did not ensure 1.) Continuous Positive Airway Pressure (CPAP) equipment and maintenance was provided for one resident (#12) out of one resident observed and 2.) Signage for oxygen use for five out of 17 rooms in one hallway ([NAME]) out of 4 hallways for four out of four days observed.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to honor the choice of one (#58) out of twenty-three sampled residents related to the preferred use of side rails for mobility and the feeling of safety and failed to assist one (#93) of one sampled resident with planning a discharge to another facility closer to family.

Inspectors wroteBased on observation, interview and record review the facility failed to follow treatment recommendations related to obtaining weights on a weekly basis for one (#93) out of four residents sampled for weight loss. Findings Included: During an observation on 05/05/2025 at 10:11 a.m., Resident #93 was observed laying in bed noted to be thin in appearance. During an observation on 05/07/2025 at 12:10 p.m., Resident #93 was observed in his room with his bedside table in front of him with his lunch tray. On his tray was a plate with spaghetti, green vegetables, a dinner roll, pudding and a piece of pie. In a follow up interview on 12:43 p.m., Resident #93 stated he ate his dinner roll and something else but could not remember what it was. During an interview on 05/07/2025 at 1:41 p.m., Staff E, Certified Nursing Assistant (CNA) stated Resident #93 ate about 25% of his meal. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide optimal nutrition for one (#78) of one resident sampled for enteral feeding.

Inspectors wroteBased on record review and interviews, the facility did not ensure there was documented communication of coordination of care with the dialysis center for one (#81) of one resident reviewed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to execute physician orders as recommended by the Consulting Pharmacist for two residents (#68 and #81) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to administer pain medication as ordered for one resident (#13) out of five residents sampled for pain management. Findings Included: Review of Resident #13's admission record revealed an admission date of 04/03/2024. Resident #13 was admitted to the facility with diagnosis to include other sequelae following unspecified cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, need for assistance with personal care, muscle weakness (generalized), sedative, hypnotic or anxiolytic dependence, uncomplicated, anxiety disorder, unspecified, Opioid dependence, uncomplicated, major depressive disorder, recurrent, moderate. Review of Resident #13's annual Minimum Data Set (MDS), dated [DATE], revealed in Section N- Medications: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and three errors were identified for one resident (#35) of five residents observed. These errors constituted a 10% medication error rate.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure complete and accurate documentation was in the resident's medical record for two (#93 and #68) out of 23 residents sampled. Findings Included: During an interview on 05/06/2025 at 11:47 a.m., Resident #93's Family Member and Power of Attorney (POA) stated he had received a call from the facility on Friday letting him know they were putting an order for Hospice for Resident #93. He stated he was told it was because Resident #93 had recently declined and there was a change in his appetite. The POA stated he tried calling back a few times to speak with someone in regard to the Hospice Order and had not received a call back. Review of Resident #93's admission Record revealed an initial admission date of 06/28/2024 and a readmission admission date of 11/26/2024 . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services for one of three sampled residents (#2) related to assistance with a room change or assistance with a transfer to another facility as requested.

Inspectors wroteBased on observation, interviews, and record review, the facility, 1. failed to ensure allegations of neglect were investigated for one (#8) of two residents reviewed for neglect and 2. failed to have evidence that alleged violations were thoroughly investigated for two (#2 and #7) of five residents sampled for alleged violations.

Inspectors wroteBased on observations interviews, and record review the facility failed to prevent a fall with injury for one (#8) of two residents reviewed for falls.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess, care plan and identify triggers related to trauma for one (#10) of two residents reviewed.

Inspectors wroteBased on observation, interview, and photogenic evidence, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items and did not ensure the dishwasher temperature log was up to date. The failed practice had the potential to effect more than a limited number of Residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreement explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it and the agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility for three (Resident #205, Resident #55, and Resident #293) of the sampled three residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the arbitration agreement provided for the selection of a venue that was convenient to both parties for three (Resident #205, Resident #55, and Resident #293) of three sampled residents.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for two (Residents #3 and #78); and 2.) ensure the accuracy of a PASARR Level I for two (Residents #65 and #143) admitted with mental health diagnoses of four residents sampled for PASARR.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement an effective infection control program as evidence by not ensuring the appropriate hand hygiene was completed after delivering a meal tray to one (Resident #143) of one resident infected with Clostridioides Difficile (C Diff) on one of four units, failed to designate Contact precautions for one (Resident #55) of 35 sampled residents, and failed to ensure that non-dedicated equipment was cleaned in between two (Residents #7 and #145) of five residents observed during medication administration.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide timely and specific notifications to include the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS 10055 to two (Residents #341 and #48) of three sampled residents who were discharged from Medicare Part A services but remained in the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to follow the baseline care plan related to the use of oxygen for one (Resident #242) of thirty-five sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure two (#55 and #36) of two residents sampled for pressure ulcers received wound care per the physician orders.

Inspectors wroteBased on record review and staff interview, the facility failed to provide pain management services per the physician orders. The facility provided pain medication outside the physician ordered parameters for two (Residents #46 and #30) of two residents reviewed for pain management.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and three errors were identified for two (Residents #71 and #53) of five residents observed. These errors constituted a 11.11% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure insulins were removed after expiration date, medications were stored per route and not in same compartment with non-medications in one ([NAME]) of two sampled medication carts, failed to ensure one (Canterbury) of two sampled medication carts were locked while unsupervised, and failed to ensure one ([NAME]/[NAME]) of two medication rooms did not contain expired medications.

Inspectors wroteBased on observations, interviews and record review the facility failed to maintain drugs and biologicals used in the facility in a safe, secure and orderly manner in three medication carts (Canterbury Hall, [NAME] Hall, and [NAME] Hall) of four medication carts.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to implement their quality assessment and assurance measures for corrective action related to deficient practice identified on the annual survey conducted on [DATE]. Findings of deficient practice were identified during the revisit survey for three (F695, F700, and F761) of the seven citations reviewed for correction.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure resident rights for a comfortable and homelike environment by not maintaining comfortable sound levels for residents and maintaining the dignity of one resident (#57) related to 1. one resident (#57) of thirty-one sampled residents yelling and calling out loudly and repetitively during four days (5/24/2021, 5/25/2021, 5/26/2021, and 5/27/2021) of four days observed and, 2. the use of mechanical floor cleaning machines by housekeeping staff in three halls ([NAME], Canterbury, and [NAME]) of four halls while residents were still sleeping for two days (5/24/2021 and 5/25/2021) of four days observed, and 3. [...]

Inspectors wroteBased on observations, interviews and medical record review, the facility did not ensure a comprehensive person-centered care plan was developed for bed rail/bed enablers and failed to implement interventions for bed positioning and reducing loud noises to prevent agitation for one resident (#57) of thirty-one sampled residents for three days (5/24/2021, 5/25/2021, and 5/26/2021) of four days observed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide wound care in a sanitary manner that would promote healing for two residents (#61 and #26) out of two residents as evidenced by cleaning and dressing three separate wounds at the same time; not completing hand hygiene between the cleaning and dressing of wounds; leaving wounds uncovered; and not wearing personal protective equipment during wound care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to oxygen and humidification therapy, consistent with professional standards of practice for one resident (#15) of one resident investigated for respiratory care.

Inspectors wroteBased on observations, interviews and medical record review, the facility failed to did not ensure an assessment for bed rails/enablers, a consent was received for use of bed rails/enablers or a physician order was received for bed rails/enablers for one resident (#57) of thirty-one sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a repeated pharmacy recommendation was responded to within a timely manner for one resident (#56) of five residents reviewed for unnecessary medications.