The Blossoms at Oakdale Rehab & Nursing Center

Inspectors wroteBased on interviews, record review, and facility document review, it was determined that the facility failed to ensure a resident with a pressure ulcer received the necessary treatment to promote healing for one (Resident #110) of one resident. The facility received Resident #110 with a stage III ulcer on 03/13/2025. The first documented applied dressing was on 03/24/2025.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that food was dated properly, food was sealed properly, drip pans under the stove top were cleaned, and that cross contamination did not occur during 2 of 2 observations in the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's Advance Directive was signed by resident or resident's power of attorney regarding the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #49) of 1 resident reviewed for advanced directives/

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the environment was clean and hazard free on the secure unit (200 Hall) affecting 14 residents. A review of the facility policy titled Accidents and Hazards Policy, with a review date of 01/2024, indicated the facility strives to ensure that the resident environment remains as free of accidents and hazards as possible. A review of the facility document titled Housekeeping 200 Hall Cleaning Schedule, undated, indicated that handrails are included in the cleaning check list. On 01/14/2025 at 9:19 AM, the surveyor observed in room [ROOM NUMBER] that the vents were missing on the air conditioning and heating unit for the room, exposing metal edges and electrical components to Resident #60 who resides in the room. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for one out of one resident (Resident #69) and ensuring residents face and nails were cleaned before or after meals for one out of one resident (Resident #76). The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed Resident #69 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. A review of Resident #69's Care Plan, revised on 11/12/2024, revealed the resident had an ADL self-care performance deficit related to hemiplegia left side, strokes, and contractures of his left hand. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure 1 of 1 sampled (Resident 47) resident was transferred from the chair to bed appropriately with a lift belt to prevent injury. The facility failed to ensure 1 of 1 sampled (Resident 62) the resident' environment remains as free of accident hazards as is possible. The facility failed to ensure 1 of 1 sampled (Resident 2) received adequate supervision to prevent accidents.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure an effective infection control program was implemented to prevent the potential spread of Clostridium Difficile (C. diff). for 1 resident (Resident #66) of 1 resident reviewed for isolation precautions, and the facility failed to ensure a gown was worn for 1 (Resident #39) of 1 resident that was on Enhanced Barrier Precautions.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's discharge/transfer information was sent in a timely manner to the Office of the Ombudsman, affecting 1 (Resident 28) of 1 resident sampled for transfers and discharge, and any resident discharged or transferred since the system change.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a resident or their representative received a written notice of the bed hold policy in a language they can understand for 1 of 1 sampled (Resident 28) resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the state designated authority was informed when 1 (Resident #39) of 2 (Resident #39 and #41) sampled residents reviewed for Preadmission Screening and Resident Review (PASARR) received a new diagnosis that required evaluation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician order was followed for a dose reduction for 1 (Resident #43) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had a functional call light, and that call light was kept in reach to prevent accidents and injuries for 1 (Resident 25) of 1 resident sampled for resident communication availability and functionality. A review of Medical Diagnosis revealed Resident 25 with a diagnoses of dementia, stroke, and heart failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 suggest a Brief Interview for Mental Status (BIMS) score of 00 (00-7 indicates severe cognitive impairment). Section GG0120 reveals resident uses a walker, and section GG0170 indicates Resident 25 can walk 50 feet with supervision.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide pharmaceuticals to meet the needs for 1 (Resident #27) of 1 sampled resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed foods were processed to the correct consistency to meet the needs of 4 residents who had physician's order for a pureed diet according to a list provided by the Dietary Manager on 01/22/24 at 12:05 PM.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for, (677) providing nail care for resident dependent on staff. The failed practice had the potential to affect 89 residents as identified on the Census by Hall provided by the Administrator on 01/22/24 at 12:00 pm.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff followed contact precautions including the appropriate use of Personal Protective Equipment (PPE) and Hand Hygiene during resident care and after exiting Contact Isolation rooms, to prevent the potential spread of infection to other residents for 1 (Resident #27) of 1 sampled resident who was in contact isolation due to positive Clostridium Difficile Colitis (C-Diff). This failed practice had the potential to affect 15 residents who required the use of the mechanical lift, as documented by a list of residents provided by the Nurse Consultant on 01/26/24 at 10:30 am.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 1 (Resident #31) of 31 (Residents #4, #8, #9, #17, #19, #20, #23, #25, #27, #30, #31, #32, #35, #40, #41, #45, #46, #49, #57, #58, #59, #73, #75, #83, #84, #85, #87, #243, #246, and #247) sampled residents who required assistance with personal hygiene and grooming.