A list of the most recent deficiencies for Blue Stream Rehab and Nursing. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-27 | 2024-04-09 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-02-27 | 2024-04-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-27 | 2024-04-09 | 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 | 2024-02-27 | 2024-04-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-27 | 2024-04-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-27 | 2024-04-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-27 | 2024-04-09 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-02-27 | 2024-04-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-27 | 2024-04-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-27 | 2024-04-09 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-27 | 2024-04-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-27 | 2024-04-09 | Y |
| 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 | 2024-02-27 | 2024-04-09 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-02-27 | 2024-04-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-27 | 2024-04-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-27 | 2024-02-27 | 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 | 2023-09-26 | 2023-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-26 | 2023-10-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-26 | 2023-10-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-26 | 2023-10-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-26 | 2023-10-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-26 | 2023-10-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-03 | 2023-08-21 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-01 | 2023-03-08 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-22 | 2022-12-28 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-11-22 | 2022-12-28 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-11-22 | 2022-12-28 | 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 | 2022-11-22 | 2022-12-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-22 | 2022-12-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-22 | 2022-12-28 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-22 | 2022-12-28 | 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 | 2022-11-22 | 2022-12-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-22 | 2022-12-28 | 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 | 2022-11-22 | 2022-12-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-22 | 2022-12-28 | 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 | 2022-11-22 | 2022-12-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-11-22 | 2022-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-22 | 2022-12-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-22 | 2022-12-28 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-11-22 | 2022-12-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-22 | 2022-12-28 | Y |
| 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 | 2022-11-14 | 2022-12-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-14 | 2022-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-14 | 2022-12-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-14 | 2022-12-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-14 | 2022-12-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-14 | 2022-12-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-14 | 2022-12-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-14 | 2022-12-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-06 | 2022-06-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-06 | 2022-06-15 | 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 | 2022-05-06 | 2022-06-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-06 | 2022-06-15 | Y |
| 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 | 2021-12-21 | 2022-01-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-21 | 2022-01-21 | 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 | 2020-01-23 | 2020-02-24 | 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 | 2020-01-23 | 2020-02-24 | 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 | 2020-01-23 | 2020-02-24 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2020-01-23 | 2020-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-23 | 2020-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-23 | 2020-02-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-23 | 2020-02-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-21 | 2020-02-24 | 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 | 2020-01-21 | 2020-02-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Construct fire resistant interior walls. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-21 | 2020-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-21 | 2020-02-24 | 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 | 2018-11-20 | 2018-12-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-20 | 2018-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-20 | 2018-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-20 | 2018-12-14 | 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 | 2018-11-20 | 2018-12-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-11-21 | 2018-12-14 | N |
