Bluestone Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bluestone Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 30, 2026

  Based upon record review, staff interviews, resident interview, and observation, the facility failed to maintain a resident environment as free from accident hazards as possible. This was true for three (3) of the three residents reviewed during the long term care survey process. The facility's failure to thoroughly review circumstances and change the processes for deliveries to residents created a risk of serious harm related to residents ordering over-the-counter medications known to be abused as well as THC gummies and offering them to other residents. Resident identifiers: #27, #54, #57 #5 and #42. Facility census: 57. […]

• Immediate jeopardy, patternF675Aug 31, 2021

  Based on observation, medical record reviews and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for all residents residing on third (3rd) floor. Failure to deploy licensed nurses (RN's and/or LPN's) to provide initial and ongoing assessments of the clinical needs of the residents including any acute changes in condition, such as cardiac/respiratory failure, choking, hemorrhaging, poor glycemic control, onset of [CONDITION(S)], behavioral emergencies, or falls resulting in head injuries or fractures, and failure to deploy staff to provide ongoing monitoring and supervision of staff to assure… […]

• Immediate jeopardy, patternF684Aug 31, 2021

  Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice had the potential to affect four (4) of six (6) residents receiving insulin medications. Resident identifiers: #10, #22, #29, #5. Facility census: 39. The state agency determined these failures placed Residents #10, #22, #29, #5 in an immediate jeopardy situation due to potential complications from [CONDITION(S)] or [CONDITION(S)] resulting from failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted an abatement plan of correction (APOC) at 7:35 PM on 08/24/21. […]

• Immediate jeopardy, patternF725Aug 31, 2021

  Based on observation, medical record reviews and staff interviews, the facility failed to deploy staff to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for all residents residing on third (3rd) floor. Failure to deploy licensed nurses (RN's and/or LPN's) to provide initial and ongoing assessments of the clinical needs of the residents including any acute changes in condition, such as cardiac/respiratory failure, choking, hemorrhaging, poor glycemic control, onset of [CONDITION(S)], behavioral emergencies, or falls resulting in head injuries or fractures, and failure to deploy staff to provide ongoing monitoring and supervision of… […]

• Actual harm, isolatedF600Apr 30, 2026

  Based on resident interview and record review the facility failed to protect two (2) residents from neglect by failing to provide care timely incontinence care Resident #1 and failing to provide the correct texture of food for Resident #3. Resident identiifers: #1, and #3. Resident #1 sustained actual physical harm from this action. Facility Census 57. Findings Included: Findings include: a) Resident #1 A policy titled Abuse includes a definition for neglect that reads: neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]