A list of the most recent deficiencies for Regency at Bluffs Park. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-28 | 2023-12-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-28 | 2023-12-24 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-03 | 2023-04-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-06 | 2023-03-02 | 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 | 2023-02-06 | 2023-03-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-06 | 2023-03-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-06 | 2023-03-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-06 | 2023-03-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-06 | 2023-03-02 | 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 | 2023-02-06 | 2023-03-02 | 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 | 2023-02-06 | 2023-03-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-06 | 2023-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-06 | 2023-03-02 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-06 | 2023-03-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-06 | 2023-03-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-06 | 2023-03-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-06 | 2023-03-02 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-03 | 2023-03-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-20 | 2022-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-20 | 2022-01-24 | 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 | 2021-12-20 | 2022-01-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-20 | 2022-01-24 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-12-20 | 2022-01-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-20 | 2022-01-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-20 | 2022-01-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-20 | 2022-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-20 | 2022-01-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-20 | 2022-01-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-20 | 2022-01-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-20 | 2022-01-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-20 | 2022-01-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-20 | 2022-01-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-20 | 2022-01-24 | 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 | 2021-12-20 | 2022-01-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-20 | 2022-01-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-20 | 2022-01-24 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-14 | 2022-01-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-12-14 | 2022-01-24 | 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 | 2021-12-14 | 2022-01-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-14 | 2022-01-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-14 | 2022-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-09 | 2021-06-23 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-04 | 2020-01-08 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-12-04 | 2020-01-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-04 | 2020-01-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-04 | 2020-01-08 | 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 | 2019-12-04 | 2020-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-04 | 2020-01-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-04 | 2020-01-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-04 | 2020-01-08 | N |
