Most Recent Deficiencies for Bloomington Rehabilitation and Hcc

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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