The Bluffs Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, staff interviews, record reviews, facility's investigation review, and facility policy review, the facility failed to provide adequate supervision to prevent a cognitively impaired resident, from exiting the facility and entering an uncontrolled, hazardous environment without staff awareness for one (1) of three (3) residents reviewed for elopement. Resident #1. This failure resulted in the resident propelling in a wheelchair approximately one-half (0.5) mile down the facility driveway and across a busy roadway, where environmental hazards included a steep ditch and wooded area, creating a situation that was likely to cause serious injury, harm, impairment, or death. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/14/26 and existed at 42 CFR: [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) when staff did not wear a gown during Percutaneous Endoscopic Gastrostomy (PEG) tube medication administration for one (1) of four (4) residents reviewed for infection control practices. Resident #1. Findings Included: Record review of facility policy, Enhanced Barrier Precautions, latest review date 6/30/25, revealed, Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following:.indwelling medical devices. Indwelling medical device examples include.feeding tubes. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to complete a baseline care plan that included the minimum healthcare information necessary to provide effective, person-centered care. This failure resulted in the residents' transfer needs not being identified or communicated to staff. This deficient practice was identified for one (1) of five (5) residents reviewed for baseline care plans (Resident #1). Cross-reference F689.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Resident #1 was transferred safely in accordance with her assessed needs. Staff performed a manual transfer instead of using the required total lift, which resulted in a traumatic injury to the resident's right leg. This deficient practice was identified for one (1) of three (3) residents reviewed for accident hazards (Resident #1).

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to ensure that a resident was free from restraints for one (1) of three (3) residents reviewed: Resident #1. Based on the implementation of the facility's corrective actions on 2/18/25, the deficient practice was determined to be past noncompliance, and the facility was found in compliance as of 2/19/25. Findings Include: A review of the facility policy titled Facility Policy on Personal Safety Devices (PSDs) with a revision date of 02/2025 - Enablers - Side Rails and Restraints revealed the following: Restraint Policy Intent: Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience . [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to provide a Registered Nurse (RN) eight (8) hours a day for one (1) of 14 staffing days reviewed. Findings Include Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing with a review date of 3-2023 revealed under Policy Interpretation and Implementation: Sufficient Staffing .A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week . Record review of the Staffing Grid for the dates of 12/24/24 through 1/6/25 revealed there was no RN coverage on 12/25/24. An interview on 1/6/25 at 11:15 AM with the Director of Nurses (DON) confirmed there was no RN coverage on 12/25/24. She stated that the RN that was scheduled did not call in or show up and no one notified her. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of the four quarters reviewed.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review the facility failed to send a written transfer/discharge notice to a resident or resident representative for a hospital transfer for three (3) of 3 residents reviewed.

Inspectors wroteBased on staff and resident interview, record review, and facility policy review the facility failed to send a bed hold notice to a resident or resident representative following a transfer for three (3) of 3 resident hospitalizations reviewed. Residents #8, # 27, and #45 Findings Include Record review of the facility policy, titled Transfer or Discharge Documentation and Notice with a review date of 5/17/24 revealed under Policy Interpretation and Implementation .5. The resident and representative are notified in writing the following information .e. the facility bed hold policy . Resident #8 Record review Discharge Minimum Data Set (MDS) for Resident #8 with an Assessment Reference Date of 8/22/24 revealed, Section A-2000: discharge date : [DATE] . Section A-2105: Discharge Status: coded Short-Term General Hospital. [...]

Inspectors wroteBased on observation, resident and staff interviews, record reviews, and facility policy reviews, the facility failed to implement a comprehensive care plan for personal hygiene for three (3) of 23 resident care plans reviewed.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by failing to utilize proper hand hygiene for one (1) of five (5) resident direct care observations.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to honor a resident 's preferences for (1) one of 23 sampled residents.

Inspectors wroteBased on observations, resident and staff interviews, and facility policy reviews, the facility failed to provide a clean, comfortable, and homelike environment as evidenced by broken blinds or window coverings on three (3) of six (6) hallways observed during survey. Rooms 203, 505, 601, and 607.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to implement a baseline care plan related to preferences and personal hygiene care for (1) one of 29 resident care plans reviewed. (Resident #195)

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene for four (4) of 29 sampled residents.

Inspectors wroteBased on staff interviews, record review, and facility policy review the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for a Resident, as evidenced by incorrectly coding anticoagulant medication usage during the 7-day observation look-back period for 1 (one) of three (3) residents reviewed for anticoagulant use.

Inspectors wroteBased on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to protect a resident from verbal abuse for one (1) of 23 sampled residents. Resident #60. Findings Included: A review of the facility's policy titled Policy for Prohibition of Abuse, Neglect, and Misappropriation of Property with no revision date revealed under Intent .Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Record review of the facility's investigation revealed that on 9/9/24 at 9:30 AM, Resident #60 reported that Certified Nursing Assistant (CNA) #5 made a verbal threat toward him on 9/8/24. Resident #60 stated that CNA #5 asked him to throw something in the trash, and when he refused, she responded by telling him she would run him over with her truck. [...]

Inspectors wroteBased on observation, staff interview, facility policy review, and record review, the facility failed to develop a care plan for placement of splints to maintain or prevent worsening of contractures for two (2) of 22 resident reviewed with a contracture.

Inspectors wroteBased on observation, staff and resident interview, facility policy review, and record review, the facility failed to utilize splints for residents to maintain or prevent worsening of contractures for two (2) of 22 residents reviewed with contractures.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to ensure a medication was properly stored as evidenced by a vial of Albuterol Sulfate being left on a resident's bedside table for (1) of 21 rooms viewed with respiratory treatments. Resident #252.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to perform hand hygiene after removing gloves during resident care for two (2) of seven (7) residents observed for staff performance of hand hygiene during resident care. Resident # 36 and Resident # 66.

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to notify the Resident Representative (RR) of a change in condition and hospital transfer for a resident for one (1) of five (5) residents reviewed for transfer/discharge.

Inspectors wroteBased on staff and resident interviews and facility policy review and activity calendar review the facility failed to provide activities to meet the needs of the residents for four (4) of six (6) resident's in attendance at the resident council meeting.

Inspectors wroteBased on staff interviews, facility policy and record review the facility failed to notify a Resident Representative (RR) in writing of a hospital transfer for one (1) of three (3) residents reviewed for transfer/discharge.

Inspectors wroteBased on staff interview, facility policy review and record review the facility failed to notify a Resident Representative in writing of the bed hold policy after transfer to a hospital for one (1) of three (3) resident's reviewed for transfer/ discharge.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to develop a care plan for an ordered Anticoagulant (AC) and a Peripherally Inserted Central Catheter (PICC) line for two (2) of 25 resident's reviewed for care plans. Resident #18 and Resident #82.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to administer Peripherally Inserted Central Catheter (PICC) flushes in accordance with professional standards of practice for one (1) of two (2) resident's reviewed for PICC line care. Resident #82 Findings Include: Review of the facility's policy, Chartwell Flushing Guidelines (undated) revealed, Adults .Type of Device .Central line: RN (Registered Nurse) Bedside PICC (Peripherally Inserted Central Catheter) .Flush Solution and Volume .Heparinized Saline (Heparin) 100 units/ml (milliliter) (5 ml) .Frequency and Documentation .Daily OR after each use . [...]