Most Recent Deficiencies for Bloomington Rehabilitation and Hcc
Updated as of April 01, 2022
A list of the most recent deficiencies for Bloomington Rehabilitation and Hcc. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-23 | 2022-03-16 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-23 | 2022-03-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-23 | 2022-03-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-23 | 2022-03-16 | Y |
| 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 | 2022-02-23 | 2022-03-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-03-16 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-02-23 | 2022-03-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-23 | 2022-03-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-14 | 2021-12-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-14 | 2021-11-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-14 | 2021-11-01 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-14 | 2021-11-01 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-10-14 | 2021-11-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-16 | 2021-09-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-16 | 2021-09-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-16 | 2021-09-05 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2021-08-16 | 2021-09-05 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-06 | 2021-06-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-06 | 2021-05-22 | 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 | 2021-05-06 | 2021-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-28 | 2021-05-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-28 | 2021-05-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-28 | 2021-05-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-04-28 | 2021-05-21 | 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 | 2021-04-28 | 2021-05-21 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-04-28 | 2021-05-21 | 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 | 2021-04-28 | 2021-05-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-28 | 2021-05-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-04-28 | 2021-05-21 | N |
| Respond appropriately to all alleged violations. | Health | 2021-02-22 | 2021-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-22 | 2021-03-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-22 | 2021-03-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-02-11 | 2021-03-01 | Y |
| 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 | 2021-02-11 | 2021-03-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-08-19 | 2020-09-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-08-19 | 2020-09-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-19 | 2020-09-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-19 | 2020-09-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-08-19 | 2020-09-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-05 | 2020-03-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-05 | 2020-03-03 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2020-02-05 | 2020-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-05 | 2020-03-03 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2020-02-05 | 2020-03-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-12 | 2019-11-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-11-12 | 2019-11-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-24 | 2019-11-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-24 | 2019-11-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-10-24 | 2019-11-19 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-10-24 | 2019-11-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-24 | 2019-11-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-11-19 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-13 | 2019-08-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-08-13 | 2019-08-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-13 | 2019-08-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-13 | 2019-08-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-13 | 2019-08-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-08 | 2019-08-25 | 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 | 2019-08-08 | 2019-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-08 | 2019-08-25 | 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 | 2019-08-08 | 2019-08-22 | 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 | 2019-07-24 | 2019-07-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-18 | 2019-07-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-18 | 2019-07-10 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-06-18 | 2019-07-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-18 | 2019-07-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-18 | 2019-07-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-18 | 2019-07-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-09 | 2019-06-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-09 | 2019-06-05 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-05-09 | 2019-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-09 | 2019-05-28 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-05-09 | 2019-05-28 | Y |
| 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 | 2019-05-09 | 2019-05-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-05-09 | 2019-05-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-17 | 2019-04-18 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-31 | 2018-12-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-26 | 2018-11-12 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2018-10-26 | 2018-11-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-26 | 2018-11-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-26 | 2018-11-12 | 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 | 2018-10-26 | 2018-11-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-10-26 | 2018-11-12 | 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 | 2018-10-26 | 2018-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-26 | 2018-11-12 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-26 | 2018-11-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-10-31 | 2018-11-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-10-31 | 2018-11-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-31 | 2018-11-09 | N |
