Deficiency Records for The Estates at Bloomington LLC
Updated as of January 01, 2022
This is not the most recent data for The Estates at Bloomington LLC. For the most recent information, click here.
A list of the most recent deficiencies for The Estates at Bloomington LLC. 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? |
|---|---|---|---|---|
| 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 | 2021-08-27 | 2021-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-27 | 2021-10-04 | 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 | 2021-08-27 | 2021-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-27 | 2021-10-04 | N |
| 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 | 2021-08-27 | 2021-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-10-04 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-08-27 | 2021-10-04 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-03-09 | 2021-04-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-02-10 | 2021-03-19 | 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 | 2021-02-10 | 2021-03-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-05-01 | 2020-06-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-13 | 2019-05-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-18 | 2019-05-04 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-13 | 2019-03-29 | N |
| Post nurse staffing information every day. | Health | 2019-02-13 | 2019-03-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-13 | 2019-03-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-13 | 2019-03-29 | 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 | 2019-02-13 | 2019-03-29 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-02-13 | 2019-03-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-13 | 2019-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-13 | 2019-03-29 | 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 | 2019-02-13 | 2019-03-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-13 | 2019-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-13 | 2019-03-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-13 | 2019-03-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-13 | 2019-03-29 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-13 | 2019-03-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-13 | 2019-03-29 | Y |
| 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 | 2019-02-13 | 2019-03-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-13 | 2019-03-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-13 | 2019-03-29 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-13 | 2019-03-29 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-13 | 2019-03-29 | 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 | 2019-02-13 | 2019-03-29 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-02-13 | 2019-03-29 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide activities to meet all resident's needs. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-13 | 2019-03-29 | 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 | 2019-02-13 | 2019-03-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-13 | 2019-03-29 | 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 | 2019-02-13 | 2019-03-29 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-02-13 | 2019-03-29 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-02-13 | 2019-03-29 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-02-13 | 2019-03-29 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-02-13 | 2019-03-29 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-02-13 | 2019-03-29 | Y |
| Keep all essential equipment working safely. | Health | 2019-02-13 | 2019-03-29 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-13 | 2019-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-06 | 2019-03-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-06 | 2019-03-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-06 | 2019-03-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-01 | 2018-01-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2017-12-01 | 2018-01-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2017-12-01 | 2018-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2017-12-01 | 2018-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-01 | 2018-01-10 | 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 | 2017-12-01 | 2018-01-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2017-12-01 | 2018-01-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-01 | 2018-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-01 | 2018-01-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2017-12-01 | 2018-01-10 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2017-12-01 | 2018-01-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2017-12-01 | 2018-01-10 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2017-12-01 | 2018-01-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-12-01 | 2018-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-05 | 2018-01-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-12-05 | 2018-01-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2017-12-01 | 2018-01-10 | N |
