Bluestone Health And Rehabilitation
BLUESTONE HEALTH AND REHABILITATION in BLUEFIELD, WV — inspection on April 30, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
establish a grievance policy and make prompt efforts to resolve grievances.
and/or their responsible party to exercise his or her right to file an anonymous grievance for facility
Facility census: 57. a) Resident Council Resident Council meeting was held on 04/21/2026 at 11:00 AM with a group of 11 (eleven) residents who reported they had no method to anonymously file a grievance.
Residents reported they did not want to report complaints for fear of retaliation.
They felt concerns brought up in the resident council were not taken seriously. An interview with the Social Worker on 04/21/26 at 6:39 PM revealed there was no method for an anonymous grievance.
She reported residents and family members had to ask a nurse or department head for a grievance form.
Review of the Facility policy titled Grievances/Complaints states that residents and their representatives have the right to file grievances, either orally or in writing, with facility staff or the agency designated to hear grievances (e.g., the State Ombudsman).
The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
515186 04/30/2026
Bluestone Health and Rehabilitation 1600 Bland Street Bluefield, WV 24701
cheese on dinner tray.
Her diet order is for mechanical soft.
Resident ate some of the grilled cheese
and got her another one that she could eat without problem.
Lumina contacted and spoke with [the
episodes to call back.
The diet orders for Resident #2 include mechanical soft texture (a diet that consists of foods that are moist, soft-textured and easily formed into a bolus).
The Diet and Nutrition Care Manual for a mechanical soft diet lists grilled sandwiches as foods to avoid.
An interview with nurse consultant #87 on 04/29/26 at 1:30PM confirmed this incident occurred according to the documentation and was not reported.
515186 04/30/2026
Bluestone Health and Rehabilitation 1600 Bland Street Bluefield, WV 24701
During an interview with Occupational Therapist (OT) #62 on 04/22/26 at 1:27 PM, she confirmed the splinting order should be for the right hand. An interview with the Director of Nursing on 04/28/26 at 1:25 PM confirmed that the orders and the care plan are written to place a splint on Resident #18's functional hand rather than her contracted hand. b) Resident #27 During a record review, an order for Resident #27's Humalog Kwikpen dated 02/09/26 included, hold for [blood sugar] BS less than 100 and call provider for [blood sugar] BS over 400. A review of the Medication Administration Record for March and April of 2026 showed the following dates with blood sugar over 400:03/02/2603/03/2603/06/2603/11/2603/12/2603/16/2603/17/2603/30/2603/31/2604/03/26The facility could not provide proof of contacting the provider when blood sugars were over 400.Registered Nurse Consultant #87 confirmed at 12:05 PM on 04/29/26 that according to documentation the provider was not notified on the above dates when blood sugar was over 400.
515186 04/30/2026
Bluestone Health and Rehabilitation 1600 Bland Street Bluefield, WV 24701
During an interview with LPN #65 on 04/14/26 at 1:05 PM who confirmed floor matt was not in place and statedI'll get that down now they just laid Resident #54 down c) Resident #57 During a check for fall prevention measures on 04/23/26 at 9:15AM, Resident #57 was observed lying in his bed with the bed not in the low position.
A review of the care plan for Resident #57 includes the following: RISK FOR FALLS: the resident is at riskfor falls related to: muscle weakness,cognitive impairment, incontinence,psychoactive medication use, recenthospitalizations, visual impairment; historyof traumatic brain injury and multiple CVAswith deficits.
Bed in lowest positionDate Initiated: 12/05/2025 It was confirmed in an interview with Registered Nurse Consultant #86 that Resident #57's bed was not in lowest position with resident in the bed at 04/23/26 at 9:21 AM.
515186 04/30/2026
Bluestone Health and Rehabilitation 1600 Bland Street Bluefield, WV 24701
During an interview with the Regional Director of Operations (RDO) on 04/28/26 at 12:35 AM, the surveyor reviewed the staffing sheet discrepancy, and the findings: one NA was sleeping, and the other was conducting business on his laptop.
Review of the CASPER report also revealed the facility triggered for low weekend staffing during Quarter 1 of 2026.
515186 04/30/2026
Bluestone Health and Rehabilitation 1600 Bland Street Bluefield, WV 24701
were wrong on staffing sheet. 158.25 was posted, versus 176.71 actual hours worked.-10/07/25 Total
actual hours worked.-10/05/25 Actual number of NAs working on 1st shift is posted as three (3,)
sheet. 154,5 was posted versus 168.12 actual hours worked.
Samples of the descrepancies were reviewed with RN Consultant on 04/28/26 mid afternoon.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.