Cherry Blossom Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and a review of the facility's policy titled, Storage Area, the facility failed to ensure food safety protocols and maintain sanitary conditions, specifically concerning the disposal of expired food. Additionally, food items opened in the walk-in refrigerator and dry storage area lacked proper labeling or dates. The deficient practices had the potential to place 54 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness.

Inspectors wroteBased on resident and staff interviews, record review, and the review of the facility policy titled, Abuse Prohibition, the facility failed to protect residents from verbal and physical abuse by a staff member for one of three sampled residents (R) (R10). The deficient practice placed R10 and other residents at risk for potential verbal and physical abuse by a staff member.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Reporting and Investigating, the facility failed to report abuse for one of three residents (R10) reviewed for abuse. This deficient practice placed R10 and other facility residents at risk of potentially being abused by a staff member.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Best Practices for PASRR, the facility failed to perform a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 14 sampled residents (R) (R5). This failure had the potential for residents with mental disorders not to receive identified specialized services.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Enhanced Barrier Precautions (Contact, Enhanced Barrier, Droplet, Airborne), the facility failed to use Personal Protection Equipment (PPE) for one of 41 sampled residents (R) (R4). The deficient practice had the potential to spread infection.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled Food Preparation and Distribution, and Ice Chests and Ice Machines, the facility failed to ensure the proper sanitation of equipment, removal of outdated food, and proper storage of open food in the kitchen. The deficient practices had the potential to place residents who received an oral diet at risk of foodborne illnesses. Findings Include: Review of the facility policy titled Food Preparation and Distribution, review date 12/27/2024, revealed the Intent section stated, It is the intent of this center to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices. The Guideline section included, . Work surfaces and equipment should be cleaned and sanitized as needed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that six of six residents (Resident (R) 21, R29, R43, R44, R57, and R50) reviewed for bed rail use of 20 sample residents had documented safety assessment for the use of bed rails and the Resident or Resident Representative (RR) were advised of the risks and/or benefits of rail use. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty residents (R) (R43) reviewed had the equipment required to exit their room as desired to attend activities. This failure had the potential to affect any resident that requires a bariatric wheelchair.

Inspectors wroteBased on record review, staff interviews, and a review of the facility policy titled Abuse Policy, the facility failed to ensure that an allegation of resident to resident physical abuse was reported to the State Agency (SA) for one of one resident (R) (35) reviewed for reporting in a timely manner of 20 sampled residents within the required two hours of discovery.

Inspectors wroteBased on observation, record review, interviews, and a review of the facility policy titled, Skilled Nursing Services Patient's Plan of Care and ADL [Activities of Daily Living] Plan of Care, the facility failed to develop and implement comprehensive person-centered care plans for three residents (R) (50,112, and 44) of 20 sample residents reviewed for care plans. R50 did not have a comprehensive care plan addressing dental needs, vision, and bed rails; R112 did not have a comprehensive care plan addressing dental needs, restorative services, and pain management; and R44 did not have a comprehensive care plan addressing bed rail use.

Inspectors wroteBased on record review and interviews, the facility failed to review and revise care plan interventions for one of four residents (R) (53) reviewed for fall prevention of 20 sample residents. This failure had the potential to delay appropriate interventions for care needs and safety concerns.

Inspectors wroteBased on observation, interviews, record review, and a review of the facility policy titled Care of Fingernails/Toenails, the facility failed to provide assistance with nail care to preserve and promote the dignity of two residents (R) (21 and R57) of four residents reviewed for activities of daily living out of 20 sample residents. This failure resulted in residents' appearance that did not maintain the resident's dignity.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure one resident (R) (27) of four residents reviewed for limited range of motion of 20 sample residents received restorative services as needed to address limited range of motion in his right arm. This created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure appropriate fall interventions were implemented resulting in continued falls for one (Resident (R) 53) of four residents reviewed for falls. This failure presented a potential risk for increased falls and physical injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two eligible Certified Nurse Aides (CNAs) 1 and CNA 4 had an annual performance review completed to enable in-service education based on the outcome of the reviews. This failure could affect the skills and knowledge required to correctly and efficiently provide care for residents.

Inspectors wroteBased on observation, interview, record review, and a review of the facility policy titled, Dental Services/Oral Assessments, the facility failed to assist two of eight residents (Resident (R) 50 and R112) reviewed for dental services in obtaining routine dental care out of 20 sample residents.

Inspectors wroteBased on record review, interview, and a review of the facility policy titled, Medication Orders, the facility failed to ensure accurate documentation of medical conditions for three (Resident (R) 27, R112, and R31) of 20 sample residents. These failures had the potential to contribute to inappropriate care or unnecessary medication use.

Inspectors wroteBased on interview, record review, and a review of the facility policy titled, Antibiotic Stewardship, the facility failed to identify trends in antibiotic use, maintain documentation for clinical indication of use for antibiotics, implement systematic protocols to monitor, decrease use and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics that did not meet criteria with the potential to effect 61 census residents.

Inspectors wroteBased on record review and interview, the facility failed to implement and maintain a training program for dementia training for one of two Certified Nurse Aides (CNA1) and emergency evacuation of bariatric residents for all staff. This failure had the potential to affect the care and services provided to 27 of the 61 residents with dementia and two bariatric residents reviewed in the survey sample of 20 in the facility.

Inspectors wroteBased on record review and interview, the facility failed to implement and maintain a training program regarding the prevention of abuse and neglect for one of two Certified Nurse Aides (CNA) 1 reviewed and one of two Licensed Practical Nurses (LPN) 1 reviewed for training. This failure had the potential to affect the safety, care, and services provided to the 61 residents in the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure two of two Certified Nurse Aides (CNA) 1 and CNA 4 and two of two Licensed Practical Nurses (LPN) 1 and LPN 2, reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses indicated as admittable in the facility assessment. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present.