A list of the most recent deficiencies for The Bluffs. 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 | 2023-06-29 | 2023-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-29 | 2023-08-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-08-13 | 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 | 2023-06-29 | 2023-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-08-13 | 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 | 2023-06-29 | 2023-08-13 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-06-29 | 2023-08-13 | 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 | 2023-06-29 | 2023-08-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Have an externally vented heating system. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-06-29 | 2023-08-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-27 | 2023-06-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-09 | 2023-04-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-27 | 2023-03-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-18 | 2023-01-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-14 | 2022-08-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-13 | 2022-05-18 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-11 | 2022-05-18 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-03 | 2022-02-16 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-06-04 | 2021-07-19 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-06-04 | 2021-07-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-04 | 2021-07-19 | 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 | 2021-06-04 | 2021-07-19 | N |
| Post nurse staffing information every day. | Health | 2021-06-04 | 2021-07-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-04 | 2021-07-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-04 | 2021-07-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-04 | 2021-07-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-04 | 2021-07-19 | 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 | 2021-06-04 | 2021-07-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-06-04 | 2021-07-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-22 | 2019-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-22 | 2019-12-20 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-11-22 | 2019-12-20 | 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 | 2019-11-22 | 2019-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-22 | 2019-12-20 | N |
