A list of the most recent deficiencies for Blue River Healthcare, Inc. 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? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-11-28 | 2023-12-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-28 | 2023-12-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-28 | 2023-11-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-11 | 2023-08-31 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-27 | 2023-08-31 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-03-10 | 2022-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-10 | 2022-03-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-09 | 2022-03-29 | 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 | 2022-03-09 | 2022-03-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-09 | 2022-03-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-09 | 2022-03-29 | 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 | 2019-07-31 | 2019-10-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-31 | 2019-10-15 | 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 | 2019-07-31 | 2019-08-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-31 | 2019-08-25 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-31 | 2019-08-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-31 | 2019-08-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-31 | 2019-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-31 | 2019-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-31 | 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 | 2019-07-31 | 2019-08-25 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-07-31 | 2019-08-25 | 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 | 2019-07-31 | 2019-08-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-31 | 2019-08-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-07-31 | 2019-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-31 | 2019-08-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-31 | 2019-08-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-08-01 | 2019-08-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-01 | 2019-08-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-01 | 2019-08-25 | 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 | 2019-08-01 | 2019-08-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-31 | 2019-08-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-31 | 2019-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-01 | 2019-08-15 | N |
| Have an externally vented heating system. | Fire Safety | 2019-08-01 | 2019-08-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-01 | 2019-08-02 | N |
