The Blossoms at Breckenridge Rehab & Nursing Cente

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment was maintained for three (Resident #1, Resident # 37 and Resident #16) of three residents reviewed.

Inspectors wroteBased on observations, interviews, record review, and facility document review, the facility failed to ensure a resident who was at risk for elopement was adequately supervised in order to prevent the resident eloping from the secure unit for one (Resident #2) of three residents reviewed for accidents and supervision. The failed practice resulted in past noncompliance at the level of harm, which had the likelihood of causing more than minimal harm to Resident #2, who resided on the secure unit. The Administrator was notified of the past harm situation on 09/12/2025 at 3:50 PM.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse for 2 (Residents #3 and #5) of 3 sampled residents reviewed for abuse. Specifically, the facility failed to ensure Resident #3 and #5 were free from emotional and physical abuse. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, §483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 12/30/2024 at 10:40 PM, when Licensed Practical Nurse (LPN) #3 made loud and aggressive statements while standing over Resident #5. [...]

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to report an alleged violation involving abuse to the proper state agency within the allotted time frame for 1 (Resident #3) of 1 sampled resident reviewed for abuse allegations.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to develop a comprehensive care plan for one (Resident #5) of one resident reviewed for care plans, specifically that a resident ' s post-traumatic stress disorder diagnosis was addressed in the resident ' s care plan.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods stored in the dry storage areas were covered, sealed and dated; 1 of 2 ice machines were maintained in clean and sanitary condition; the kitchen light fixtures were covered; ceiling tiles and door frames were maintained in good repair and were free of chips, stains and rust; baseboards were secured and were maintained in clean sanitary conditions, and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 81 residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a bottle of acid reducer liquid medication was properly stored in the refrigerator, per the pharmacy instructions on the bottle, for 1 (Resident #33) of 1 sampled resident whose medication was in the 100-hall medication cart.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned, written menu to ensure that nutritionally balanced meals were provided for the residents for 1of 1 meal observed.

Inspectors wroteBased on record review and interview, the facility failed to convey funds within 30 days and send conveyed funds to the individual or probate jurisdiction administering the resident's estate for 7 ( Residents #5, #6, #7, #8, #9, #10, and #11) of 7 case mix residents reviewed for personal funds. 1. Resident #5 was admitted to facility on [DATE] and expired on [DATE]. A review of the resident #5'spersonal funds account managed by the facility revealed on [DATE] at 10:27 AM the resident's personal fund had a balance of $6,124.80. Resident #5 is receiving a social security check each month which is deposited into the resident trust fund even thought Resident #5 expired on [DATE]. 2. Resident #6 was admitted to the facility on [DATE] and expired on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food stored in the freezer was covered or sealed to prevent potential contamination or freezer burn; 1 of 2 ice machines was maintained in clean and sanitary condition to prevent potential contamination of resident beverages; the kitchen wall and door frames were maintained in good repair and were free of chips, paint peeling, stains and rust; baseboards were secured and were maintained in clean sanitary conditions; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 86 residents who received meal trays from the kitchen, (total census of (88), as identified on a list provided by the Dietary Supervisor on 12/15/2023 at 12:01 PM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was assessed and deemed safe for self-administration for 1 (Resident #86) of 1 sampled resident on the 400 Hall whose medication was left at the bedside. This failed practice had the potential to affect 20 residents who resided on the 400 Hall.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the bathroom sink was in working order to ensure access to running water to perform activities of daily living (ADLs) for 1 (Resident #86) of 20 residents who resided on the 400 Hall.

Inspectors wroteBased on observation and interview, the facility failed to ensure 4 rooms on the 100 Hall were clean and maintained a homelike environment, and staff changed gloves when cleaning resident rooms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 (Residents #1 #75, and #92) of 3 sampled residents who were dependent on staff for nail care to promote good hygiene and cleanliness.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an intervention for a fall was implemented for 1 (Resident #19) of 1 sampled resident with a major injury in the last 30 days, and razors were removed from the bathroom for 1 (Resident #78) of 2 (Residents #77 and #78) sampled residents on the 100 Hall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fluids were readily accessible to promote adequate hydration for 3 (Residents #39, #75 and #352) sampled residents and interventions were promptly implemented after continued weight loss was identified to attain or maintain acceptable nutritional status for 1 (Resident #92) of 2 (Residents #92 and #352) with weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed antipsychotic and antianxiety medications were discontinued or reevaluated for use after 14 days for 1 (Resident #92) of 2 sampled residents who were reviewed for unnecessary medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a call light was accessible to 3 (Residents #28, #59, and #89) of 11 (Residents #14, #22, #28, #39, #59, #60, #75, #86, #89, #90, and #92) sampled residents and the call light was in working order for 2 (Rooms 415-B and 303-B) of 2 rooms.

Inspectors wroteBased on interviews, the facility failed to ensure residents were informed of who the Ombudsman is, what the Ombudsman does and where the Ombudsman's contact information is located in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents, resident representatives/family, and visitors had the right to examine the results of the most recent survey conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility without asking.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 (Resident #89) of 1 sampled resident had an Advance Directive readily available in their clinical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' individualized care plans were updated to ensure appropriate care was received for 1 (Resident #75) of 1 sampled resident who had a new service or level of care ordered or provided.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physician's orders were followed for wound care for 1 (Resident #79) of 4 (Residents #2, #14, #45 and #79) sampled residents with orders for wound care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff had on appropriate Personal Protective Equipment (PPE) for 2 (Residents #19 and #39) of 5 (Residents #14 #40, #19, #39 and #352) sampled residents who were on contact isolation.

Inspectors wroteBased on record review and interview, the facility failed to ensure pneumococcal immunizations were administered to eligible residents and the immunization records were updated in the electronic medical record (EMR) for 1 (Resident #75) of 5 (Residents #1, #45, #60, #75 and #92) sampled residents.