The Blossoms at Cumberland Rehab & Nursing Center

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to prevent staff to resident abuse for one (Resident #76) of four residents reviewed for abuse.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide written bed hold notification to a resident or the resident's representative upon transfer to the hospital for two (Resident #3 and Resident #71) of two residents who were reviewed for transfers.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, interviews and facility policy review, it was determined that the facility inappropriately discharged one Resident (Resident #76) of three residents reviewed.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews, record review, and facility policy review, it was determined that the facility failed to perform blood sugar testing as ordered by a Physician for one (Resident #74) of one resident reviewed.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to provide a comfortable, homelike environment for one (Resident #38) of three residents reviewed.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to support resident's rights to accommodate a sexual relationship between consenting adults for two (Resident #3 and Resident #4) of five residents reviewed for resident rights.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to Care Plan for residents' sexual health and relationship for two (Resident #3 and Resident #4) of five residents reviewed for revised Care Plans.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to prevent resident abuse for 2 (Resident #1 and Resident #2) of 6 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure dented cans were promptly removed from stock; leftover meat products were used in a manner to maintain food quality; surfaces were cleaned to provide a sanitary environment for food preparation, floors, dish washer and kitchen walls, door and frames were free of, debris, dirt, grease, rust, stains, wall tiles were replaced; food items stored in the freezer were covered or sealed properly; expired food items were promptly removed from stock; ice machine was maintained in clean and sanitary condition; and dietary staff washed their hands before handling clean equipment for 1 of 1 meal observed.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents received wound care as per Physician's orders for 2 (Resident #2 and #48) of 2 sampled residents who were reviewed for pressure ulcer care.

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.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' decisions as to whether they desired to have, or did have, an advance directive, were documented in a prominent part of the clinical record, to ensure their wishes were known regarding acceptance or rejection of any life-sustaining treatments in the event of their incapacitation for 1 (Resident # 30) of 1 sampled resident whose clinical records were reviewed for advance directive information.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate assessments with the PASARR (Preadmission Screening and Resident Review) program by obtaining a copy of the completed Level II PASARR, so any recommendations could be incorporated into the resident's assessment, care planning and transition of care for 1 (Resident #7) of 1sample resident reviewed for PASARR.

Inspectors wroteBased on observations, interviews, record review, and facility document review, it was determined the facility failed to ensure the resident received a bath/shower per the schedule to promote good hygiene for 1 (Resident #44) of 18 sampled residents reviewed for assisting residents to perform activities of daily living (ADLs).

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure staff monitored the skin and applied ointment as ordered by the physician for 1 (Resident #36) of 1 sampled resident reviewed for skin issues.

Inspectors wroteBased on observations, interviews, record review, and facility document review, it was determined the facility failed to provide safety during the process of medication administration for one (Resident #44) of 18 sampled residents reviewed for being free of Accident Hazards/Supervision/Devices.

Inspectors wroteBased on interviews, record review, and facility document review, it was determined the facility failed to have a medication as ordered for treatment available for 1 (Resident #36) of 1 sample resident who was reviewed for pain control.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure that staff performed hand hygiene when changing gloves when contaminated during indwelling urinary irrigation catheter care for 1 (Resident #36) of 1 sampled resident reviewed for catheter care and failed to ensure staff performed hand hygiene when changing gloves during wound care for 1 (Resident #48) of 2 sampled residents observed for wound care. 1. Review of Resident # 36 ' s Order Summary revealed had diagnoses of coronary artery disease (CAD), neurogenic bladder, acute kidney failure. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/24, indicated that the resident scored 15 on the Brief Interview for Mental Status (BIMS) (13-15 indicates cognitively intact), and Resident #36 had a catheter (indwelling). a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents skin treatments were completed to promote healing per physician's orders for 3 (Residents #2, #3, and #4) of 4 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff were completing treatments per physician's orders for 3 (Residents #2, #3, and #4) of 4 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean environment on 5 (100 Hall, 300 Hall, 500 Hall, 600 Hall, and 700 Hall) halls of 6 halls where residents resided. This failed practice had the potential to affect all 68 residents who reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure licensed nursing staff demonstrated competency in the care of a resident who required weekly body audits, as evidenced by failure to accurately perform weekly body audits resulting in the resident developing gangrene in the 4th and 5th toes on the left foot, which resulted in surgical amputations of the 4th and 5th toes on the (L) foot for 1 (Resident #323) of 1 sampled resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the freezer had an open date to minimize the potential for food borne illness for residents who receive meals from the facility kitchen. This failed practice had the potential to affect 73 residents (total census: 74) who received meals from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 (Residents #23 and #66) of 14 residents who were dependent or required assistance of staff to perform facial hair removal to promote good hygiene and cleanliness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled substances remaining count was accurate and drug records of controlled substances were maintained.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physician orders were followed to maintain a medication error rate was less than 5%, for 3 (Resident #33 #69 and #323 ) of 7 (Residents #9, #12, #33, #49, #62, #63 and #323) sampled residents observed during the medication pass. The medication error rate was 21.43%, based on observations of 28 medications administered for a total of 6 errors detected.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that expired insulin vials were removed from the medication cart once the expiration date has been reached, the facility failed to ensure that controlled substances were properly removed once the seal to the medication had been broke to prevent the possible misappropriation of medication, the facility failed to ensure that medications were stored on the medication cart in original packaging to show the medication identifiers and expiration date.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was disinfected after use to prevent potential spread of infection for 17 residents who had physician orders for capillary blood glucose (CBG) monitoring. On 1/29/23 at 11:54 AM, LPN #1 performed a glucose finger stick to Resident # 33. LPN #1 took an alcohol wipe and cleaned the glucose machine for approximately 1 minute then placed the machine in the 600-medication cart drawer. LPN #1 performed a glucose finger stick on Resident #62, then cleaned the glucose machine with an alcohol wipe for approximately 25 seconds then returned the machine to the 700-medication cart drawer. On 1/29/24 at 12:24 PM, LPN #1 performed a glucose finger stick on Resident #9. LPN #1 cleaned the glucose machine for 8 seconds then returned the machine to the 700-medication cart drawer. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided with the opportunity to formulate Advance Directives other than code status, to enable them to make advance decisions regarding which measures should be provided or withheld in the event of their incapacitation for 1 (Resident #34) sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records on the secured unit, were kept private by not closing the electronic medication administration record when not in use.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Ombudsman was notified in writing of the resident's transfer to the hospital and/or discharge as required for 1 (Resident #323) of 10 (Residents #5, #8, #19, #30, #33, #37, 47, #68, #66 and #323) sampled residents who were transferred to the hospital from [DATE] to 2/2/24.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #66 had an order for a treatment to the left wrist area and the bandage was changed to prevent infection. This failed practice had the potential to affect 14 residents who resided on 600 Hall.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure a Physician Ordered nutritional diet was served and the interdisciplinary team met timely for appropriate interventions and initiated new interventions when the resident's weight continued to decline in order to minimize further weight loss and maintain nutritional status to the extent possible for 1 (Resident #62) sampled resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and flushes via percutaneous endoscopic gastrostomy (PEG) were given via gravity for 1 (Resident #12) sampled resident who had a PEG tube.