Deficiency Records for Blue Ridge Rehabilitation and Nursing
Updated as of March 01, 2024
A list of the most recent deficiencies for Blue Ridge Rehabilitation 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-11-16 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-08-24 | 2022-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-24 | 2022-11-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-24 | 2022-11-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-24 | 2022-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-24 | 2022-09-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-24 | 2022-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-24 | 2022-09-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-24 | 2022-09-20 | 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 | 2022-08-24 | 2022-09-20 | 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 | 2022-08-24 | 2022-09-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-24 | 2022-09-20 | 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 | 2021-12-09 | 2022-01-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2022-01-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-09 | 2022-01-25 | 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 | 2021-12-09 | 2022-01-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-09 | 2022-01-25 | 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 | 2021-12-09 | 2022-01-25 | 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 | 2021-12-09 | 2022-01-25 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-12-09 | 2022-01-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-12-09 | 2022-01-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-09 | 2022-01-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-09 | 2022-01-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-09 | 2022-01-25 | 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 | 2021-12-09 | 2022-01-25 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-13 | 2021-12-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-03-25 | 2019-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-25 | 2019-04-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-25 | 2019-04-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-25 | 2019-04-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-25 | 2019-04-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-07 | 2019-04-03 | N |
| 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 | 2019-03-07 | 2019-04-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-07 | 2019-04-03 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-07 | 2019-04-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-07 | 2019-04-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-07 | 2019-04-03 | 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 | 2019-03-07 | 2019-04-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-07 | 2019-04-03 | N |
| Provide or obtain dental services for each resident. | Health | 2019-03-07 | 2019-04-03 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-03-07 | 2019-04-03 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-03-07 | 2019-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-07 | 2019-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-07 | 2019-04-03 | N |
| Keep all essential equipment working safely. | Health | 2019-03-07 | 2019-04-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-17 | 2018-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-29 | 2018-05-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-29 | 2018-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-29 | 2018-05-10 | 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 | 2018-03-29 | 2018-04-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-29 | 2018-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-29 | 2018-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-29 | 2018-04-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-29 | 2018-04-24 | 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 | 2018-03-29 | 2018-04-24 | N |
