The Bluffs Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 21, 2026

  Based on observations, staff interviews, record reviews, facility's investigation review, and facility policy review, the facility failed to provide adequate supervision to prevent a cognitively impaired resident, from exiting the facility and entering an uncontrolled, hazardous environment without staff awareness for one (1) of three (3) residents reviewed for elopement. Resident #1. This failure resulted in the resident propelling in a wheelchair approximately one-half (0.5) mile down the facility driveway and across a busy roadway, where environmental hazards included a steep ditch and wooded area, creating a situation that was likely to cause serious injury, harm, impairment, or death. […]

• Actual harm, isolatedF655Sep 23, 2025

  Based on staff interviews, record review, and facility policy review, the facility failed to complete a baseline care plan that included the minimum healthcare information necessary to provide effective, person-centered care. This failure resulted in the residents' transfer needs not being identified or communicated to staff. This deficient practice was identified for one (1) of five (5) residents reviewed for baseline care plans (Resident #1). Cross-reference F689. Findings include: Review of the facility policy titled, “Care Plans-Baseline,” last reviewed 6/2/25, revealed: “The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information… […]

• Actual harm, isolatedF689Sep 23, 2025

  Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Resident #1 was transferred safely in accordance with her assessed needs. Staff performed a manual transfer instead of using the required total lift, which resulted in a traumatic injury to the resident's right leg. This deficient practice was identified for one (1) of three (3) residents reviewed for accident hazards (Resident #1). Cross-reference F655 Findings include: Review of the facility policy titled, “Safe Patient Handling and Moving Protocol,” latest review 6/18/25, revealed: “The licensed nurse will, upon resident admission, determine the level of assistance required to safely transfer the resident, while minimizing risk to resident and staff.” An… […]

• Actual harm, isolatedF656Oct 26, 2023

  Based on observation, staff interview, facility policy review, and record review, the facility failed to develop a care plan for placement of splints to maintain or prevent worsening of contractures for two (2) of 22 resident reviewed with a contracture. Resident #26 and Resident #56 Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a reviewed date of January 2023, revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. […]

• Actual harm, isolatedF688Oct 26, 2023

  Based on observation, staff and resident interview, facility policy review, and record review, the facility failed to utilize splints for residents to maintain or prevent worsening of contractures for two (2) of 22 residents reviewed with contractures. Resident #26 and Resident #56 Findings include: Review of the facility policy titled, Contracture Management Program, with a revision date of 1/23/23, revealed, Intent: To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of range of motion . Resident #26 An observation and interview, on 10/24/23 at 3:07 PM, revealed a wrist and hand splint laying on Resident #26's bed. Resident #26 stated since he finished therapy, they don't put it on much. […]