Blueberry Hill Rehabilitation and Healthcare CTR

In the surveyor’s words

From the most serious findings on record at Blueberry Hill Rehabilitation and Healthcare CTR, in the surveyor’s own words.

• Immediate jeopardy, patternF684Nov 12, 2024

  Based on observation, record review, and interview, the facility failed to ensure treatment and care in accordance with professional standards for 4 Residents (#323, #24, #70, and #2) out of a total sample of 39 residents. Specifically; 1. For Resident #323, the facility failed to follow up on abnormal labs that were drawn for a Resident with a known history of Chronic Kidney Disease, resulting in a subsequent panel of critically high labs, which required emergency hospitalization and resulted in death. 2. For Resident #24, the facility failed to ensure that a significant change in condition was monitored, assessed and reported timely to the physician for one resident who exhibited coffee ground emesis and continuous stooling of black liquid feces. 3. […]

• Immediate jeopardy, isolatedF580Nov 12, 2024

  Based on observations, interviews and record review, the facility failed to ensure timely and accurate physician notification of a significant change in a resident's status for one Resident (#24) out of a total sample of 39 residents. Specifically, for Resident #24, the facility failed to provide a covering Nurse Practitioner (NP) with complete and accurate information about a resident with coffee ground emesis and ongoing black stools, including but not limited to the Resident's significant history of bowel obstructions and Gastrointestinal (GI) bleeding, resulting in hospitalization and subsequent death. […]

• Immediate jeopardy, isolatedF600Nov 12, 2024

  Based on record review and interview, the facility failed to protect two Residents (#24 and #323), from neglect, out of a total sample of 39 residents. Specifically, 1. For Resident #24, the facility neglected to monitor, assess and notify the physician timely for the Resident who was found to be vomiting coffee ground emesis and exhibiting continuous stooling of black liquid. 2. For Resident #323, the facility neglected to a) review and intervene on abnormal laboratory tests, resulting in a delay in treatment, and subsequent hospitalization and death; b) implement treatments timely for a newly acquired pressure injury, resulting in an untreated wound for 6 days and; c) address a significant, 11%, weight loss. […]

• Immediate jeopardy, isolatedF710Nov 12, 2024

  Based on record review and interview, the facility failed to ensure physician and/or delegate supervision after a change in medical status for one Resident (#323) of a total sample of 39 residents. Specifically, the facility failed to follow up on abnormal labs that were drawn, for a Resident with a known history of Chronic Kidney Disease, resulting in critically high labs, which required emergency hospitalization and death. Findings include: Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018, indicates the following: - A physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. […]

• Actual harm, isolatedF760Feb 19, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 12/25/24, Resident #1 was administered his/her scheduled medications in the morning by his/her assigned nurse and then Nurse #1, administered another resident's medications to Resident #1 in error. Several hours later Resident #1 experienced a significant change in condition, was disoriented and became lethargic, was transferred to the Hospital Emergency Department (ED), and was admitted to the Hospital for four days due to an accidental drug overdose. […]