The Blossoms at Conway Rehab & Nursing Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure 1 of 1 ice machine was maintained in a sanitary condition; dietary staff washed their hands between clean tasks when contaminated; food stored in the freezer was covered; expired food items were promptly removed/discarded on or before the expiration or use by date; food items were free of discoloration, and hot food items were maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service for 1 of the 2 meals observed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a wheelchair was clean and sanitized for one (Resident #6) of one resident and failed to maintain and ensure clean shower rooms for residents in two (200 hall and 100 hall) of three shower rooms in the facility, to maintain a safe, clean, homelike environment.

Inspectors wroteBased on observation, record review, interview, and review of the menu, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure nutritionally balanced meals were provided for the residents for 2 of the 2 meals observed.

Inspectors wroteBased on observation, interview, and review of the mealtime schedule, the facility failed to ensure all residents who received meals from the kitchen were consistently being served at regularly scheduled times and failed to provide the residents with a dependable eating schedule for 2 of 2 meal services observed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure proper hand hygiene was performed during tracheostomy care for one (Resident #29) of 2 residents sampled for infection control.

Inspectors wroteBased on observation, record review, interview, and facility in-services, the facility failed to ensure privacy for 1 (Resident #4) sampled resident, to promote a dignified existence based on 1 of 1 observation.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure adequate and/or increased supervision was provided by staff during periods of increased exit-seeking and aggressive behaviors for 1 (Resident #4) of 3 sampled residents reviewed for elopement. The lack of effective supervision resulted in Resident #4 eloping from the facility and facility staff being unaware of the resident's whereabouts for approximately one hour before the resident walked back into the facility. At the time of the survey, there were nine residents residing in the facility who were identified as at risk for elopement. 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 residents. [...]

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for resident behaviors for 1 (Resident #4) of 1 sample mixed resident.

Inspectors wroteBased on observation and interviews, the facility failed to promote a healthy comfortable environment to support a safe living, healthy homelike and comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was utilized prior to the expiration date, that equipment was clean to prevent potential cross contamination, and that hands were washed between clean and dirty tasks. These failed practices had the ability to affect all 47 residents who receive their meals from one of one kitchen according to a list provided by the administrator on 3/7/23 at 9:15 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light was within reach for 1 (Resident #32) of 8 sampled residents who utilize their call light on Hall 100; failed to maintain resident rooms in good condition for 1 (Resident #35) sampled resident; and failed to ensure a sufficient amount of bed linen was available to maintain a homelike environment for all 47 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were showered/bathed as scheduled to promote good personal hygiene for 01 (Resident R #35); ensure residents fingernails were kept clean and free of debris for 01 (Resident #13) sample mix residents who require assistance with showering/bathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure thickened liquids were within reach and that the cooler was maintained with cold ice packs to promote adequate hydration for 01 (Resident #22) sample mix resident and the facility failed to provide services to maintain acceptable parameters of nutritional status for 01 (Resident #37) of 7 sampled residents who have a physician's order to receive fortified foods.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to assure nursing staff possessed the skill sets necessary to provide nursing services to meet the resident's needs safely and in a manner that promoted each resident's physical well-being, as evidenced by hand hygiene not being performed before putting on gloves during wound care to prevent the spread of infection for 2 (Residents #5, and #18), and the use of a mechanical lift as a care plan documented to prevent accidents for 1 (Resident #22) sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all pharmaceuticals were available for the residents during medication administration.

Inspectors wroteBased on observation and record review, the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 2 (Residents #18 and #24) of 3 residents observed during medication pass resulting in medication errors.

Inspectors wroteBased on observation and interview, the facility failed to ensure that garbage receptacles were maintained in a manner to minimize pests. The failed practice had the ability to affect all 47 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff changed gloves/washed hands when contaminated before, during and after wound care in accordance with professional standards of nursing practice, to prevent the potential spread of infection for 3 (Resident #5, #15 and #18) of 4 (Residents #5, #15, #18 and #24) sampled residents who had Physicians Orders for wound dressings changes. This failed practice had the potential to affect 6 residents who received wound care treatment /dressings changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided consistent access to personal property for 1 (Resident #46) sampled resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that before a resident was allowed to self-administer nasal spray, the Interdisciplinary Team (IDT) conducted an assessment to determine if this practice was safe, obtain a physician order for self-administration, and develop a care plan to address educating the resident on self-administration, to prevent potential errors in administration for 1 (Resident #35) sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who are care planned for mechanical lift transfers were transferred by the mechanical lift, and that they were assessed for usage of the mechanical lift in accordance with professional standards of practice for 1 (Resident # 22) sample mix resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure a deep freezer was maintained in a manner to ensure frozen food was maintained at the appropriate temperature to minimize the potential for food borne illness who could affect all 47 residents who receive their meals from one of one kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 2 (Residents #1 and #3) of 3 (Residents #1, #2 and #3) sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the call light was accessible to allow residents to summon for assistance to accommodate their individual needs for 1 (Residents #7) and failed to provide therapy recommended adaptive eating utensils to accommodate resident needs for 1 (Resident #13) of 23 (Residents #1, #7, #8, #12, #13, #14, #15, # 21, #22, #26, #27, #28, #30, #31, #32, #34, #37, #38, #41, #92, #192, #243 and #244) sampled residents who used the call light system to summon for assistance and 1 sampled resident who required adapted eating utensils.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status to reflect current services for 2 (Residents #21 and #31) of 6 (Residents #7, #12, #15, #21, #26 and #31) sampled residents who had physician orders for oxygen therapy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the comprehensive care plan was accurately developed to address current services for oxygen therapy for 2 (Residents #21 and #31) of 6 (Residents #7, #12, #15, #21, #26 and #31) sampled residents who had physician orders for oxygen therapy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of care in the care and storage of respiratory and/or nebulizer equipment was maintained for 2 (Residents #8 and #26); oxygen was ordered and administered at prescribed flow rate for 1 (Resident #31) and signage indicating No Smoking was posted on the door for 2 (Residents #21and #31) of 6 (Residents #7, #12, #15, #21, #26 and #31) sampled residents who received oxygen therapy and 11 (Residents #7, #8, #13, #15, #21, #26, #27, #31, #32, #38 and #244) nebulizer treatments.

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 meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 5 residents who received pureed diets, 9 residents who received mechanical soft diets, 2 residents who received chopped diets and 20 residents who received regular diets (total census: 38) from1 of 1 kitchen according to a list provided by the Dietary Supervisor on 12/6/2022.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a meal tray was not left to sit in a resident's room while they were out of the facility for an appointment and a new meal tray was provided instead of the residents eating the food to prevent the potential for food borne illness for 2 (Residents #27 and #243) of 2 residents who received dialysis and failed to ensure meals were served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received meal trays in their rooms on Hulan Hall as documented on a list provided by Dietary Supervisor on 12/6/2022 and 2 residents who received dialysis as documented on the Resident Matrix provided by the Minimum Data Set Coordinator on 12/6/22.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 12/6/2022.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure that chipped areas in the kitchen floors tiles were not covered with a black residue; failed to ensure food items stored in the refrigerator were covered, sealed and dated; ceiling vents were maintained in clean, sanitary conditions for food preparation to prevent the potential food borne illnesses for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded by the expiration or use by dates; foods were dated when received to assure first in, first out usage to prevent the potential for food bone illness; and dietary staff washed their hands before handling clean equipment or food items; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Binding Arbitration Agreement was explained in a manner understood by residents and representatives, explicitly granted the right to rescind the agreement within 30 days of signing, allowed the resident or representative to communicate with federal, state or local officials or Office of Long Term Care (LTC) Ombudsman, and was not required as part of the admission process for 3 (Residents #14, #38 and #192) of 3 sampled residents who signed Binding Arbitration Agreements upon admission since September 16, 2019. This failed practice had the potential to affect 121 residents admitted since the facility's last annual survey on 9/3/21.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Binding Arbitration Agreement provided for the selection of a neutral arbitrator or a venue was convenient to both parties for 3 (Residents #14, #38 and #192) of 3 sampled residents who signed Binding Arbitration Agreements upon admission since September 16, 2019. This failed practice had the potential to affect 121 residents admitted since the facility's last annual survey on 09/03/21.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident rights to visual privacy were maintained for 1 (Resident #38) of 23 (Residents #1, #7, #8, #12, #13, #14, #15, #21, #22, #26, #27, #28, #30, #31, #32, #34, #37, #38, #41, #92, #192, #243 and #244) sampled residents who was dressed in a hospital gown and the door was open.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the resident's environment was as free from accident hazards as possible, as evidenced by failure to ensure a heating pad was not used by a resident without supervision and/or facility knowledge for 1 (Resident#244) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure required notices were provided to resident/resident representatives when Medicare Part A services were no longer covered for 2 (Residents #8 and #28) of 3 (Residents #8, #28, and #92) sampled residents. This failed practice had the potential to affect 136 residents discharged since the facility's last survey per the Discharge list provided by the Consultant on 12/08/22.