Bluffs, The

In the surveyor’s words

From the most serious findings on record at Bluffs, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Nov 1, 2024

  Based on observation, interview and record review, facility staff failed to follow standard universal infection control precautions when staff used one insulin pen on three residents (Resident #7, #10, and #41), possibly creating a risk of bloodborne and bacterial pathogen transmission. The facility failed to use appropriate hand hygiene infection control practices during perineal and wound care for four (# 41, #43, #47, #105) of four sampled residents, and failed to follow Enhanced Barrier Precautions (EBP), the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms, for three (#7, #19, and #105) of four sampled residents. […]

• Actual harm, isolatedF760Feb 24, 2025

  Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 being transported to the hospital with low blood sugar. The facility census was 116. The administrator was notified on [DATE] of past Non-Compliance, which occurred on [DATE] when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on [DATE]. 1. […]

• Actual harm, isolatedF689Jan 14, 2025

  Based on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when staff failed to lower the resident appropriately in the shower chair which resulted in a compression fracture (a break in a vertebra, or bone in your spine, causes it to collapse) the resident's spine. The facility census was 115. 1. Review of the facility's use of lift machine policy, dated 11/25/2019, showed the purpose of the policy is to help lift residents who otherwise may not be transferred manually, promote comfort and maintain good body alignment while resident is being moved, to position the resident in desired location, and use controls to slowly lower resident to that location. 2. […]

• No harm, potential for more than minimal, widespreadF658Jan 30, 2026

  Based on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to ensure wound care orders were in place for one resident (Resident #123), failed to follow wound care orders for one resident (Resident #7), failed to follow orders for wrist splints to prevent or maintain contractures for one resident (Resident #19), and failed to complete neurological assessments after falls for two residents (Resident #103 and #63), out of 27 sampled residents. The facility census was 115.1. Review showed the facility failed to provide a policy that directs staff in regard to physician's orders.2. […]

• No harm, potential for more than minimal, widespreadF803Jan 30, 2026

  Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 115.1. Review of the facility lunch menus, dated 01/28/26 (Week 1, Day 4), showed the menus directed staff to provide the residents who receive pureed diets with a: -#8 (four ounces (oz.)) scoop of pureed barbequed pork;-#8 scoop of mashed potatoes with thick gravy;-#10 (3.2 oz.) scoop of pureed spinach;-#16 (two oz.) scoop of pureed dinner roll with margarine. […]