The Blossoms at Star City Rehab & Nursing Center

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure privacy and dignity was provided for 1 ( Resident #28) of 2 sampled residents reviewed for privacy and dignity.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accurately complete the care plan to address bipolar disorder and post-traumatic stress disorder (PTSD) (Resident #13) and contractures (Resident #44) for two (Resident #13 and Resident #44) of 23 sampled resident who were reviewed for care plan accuracy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure smoking paraphernalia was not stored in the resident rooms and failed to ensure residents with vape devices were assessed for safe usage for 2 (Residents #24 and #176) of 2 sampled residents reviewed for smoking.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a glucometer was disinfected per disinfectant wipe directions for one of one glucometer disinfecting observed; failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by leaving a clean linen cart uncovered and placing used hangers with clean clothes on linen cart; failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to keep dirty briefs and linen off of the floor in Resident #28 ' s room and failure to contain items during transport through the hallway.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure wound measurements were completed and wound care was documented for 1 (Resident #6) of 3 residents reviewed for skin issues.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure interventions were consistently implemented to prevent further harm or injury to a resident who had a previous fall with a major injury for 1 (Resident #3) of 3 (Residents #1, #2 and #3) residents who were reviewed for falls.

Inspectors wroteBased on observation and interview, the facility failed to ensure foods stored in the refrigerator, freezer and storage areas were sealed and dated, storage shelves were free of paint peelings, door frames, pillars, and floor tiles in the kitchen were intact to allow for thorough cleaning/disinfecting, kitchen and storage room floors were free of rust and wax build-up; the ice scoop holder was maintained in clean and sanitary condition; dietary staff washed their hands before handling clean equipment or food to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; cold foods were maintained at or below 41 degrees Fahrenheit. The failed practices had the potential to affect 86 residents who received meals from the kitchen.

Inspectors wroteBased on record review and interview the facility failed to ensure a Surety Bond was purchased, or there was an alternate means of assuring the security of all personal funds deposited in the Trust Fund Account managed by the facility, to prevent the financial loss for 75 residents who have individual Trust Fund Accounts.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that hazardous chemicals were secured in a closed locked room from wondering residents. This failed practice had the potential to affect 2 sampled Residents #49, and #51 with the potential to affect 10 Residents who wonder. The facility also failed to ensure that Resident #238 ' s environment was free from accident and hazards by making sure lift pad/sling was free of fraying to prevent accidents. This failed practice had the potential to a affect 1 Resident (238) requiring mechanical lift transfer with the potential to affect 7 sampled Residents requiring lift assistants.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu and recipe to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets and 23 residents from 1 of 1 kitchen.

Inspectors wroteBased on observation, record review and interview, the facility 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 2 meals observed. The failed practices had the potential to affect 21 residents who received their meal trays their rooms on 500 Hall, 10 residents who received meals in their rooms on [NAME] Hall 7 residents who received meals in their rooms on North Hall.

Inspectors wroteBased on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets and 2 residents who received pureed meat only.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that Resident #66 received privacy during incontinence care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 1(Resident #52) of 16 residents who have a level II PASRR.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure person centered nail care was provided to promote good hygiene and reduce the risk for infection in 1 (Resident #4) of 8 sampled residents on 500 hall requiring fingernail care assistance.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that Resident #66 received proper incontinence care. This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure tube feedings were turned off by nursing when residents were laid flat for personal care or dressing changes to prevent the risk for aspiration for 1 (Resident #3) of 2 residents receiving tube feedings.

Inspectors wroteBased on observations, interview and record review, the facility failed to complete nail care for 3 (Residents #4, #5 and #6) of 6 (Residents #1, #2, #3, #4, #5 and #6) sampled residents who required assistance of staff with activities of daily living (ADL).

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a baseline care plan within 48 hours of admission for one (Resident #5) of 6 (Residents #1, #2, #3, #4, #5 and #6) sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that there were no brown stained ceiling tiles, a hole in one ceiling tile in resident room West-6, and failed to ensure that the paint was not scuffed off on the wall behind the head of the bed, and side wall, and failed to ensure that a ceiling tile was securely attached for 1 (Resident #32) of 17 finalized sampled residents (#2, #4, #5, #19, #23, #24, #25, #26, #31, #32, #33, #36, #38, #42, #44, #45, #46). This failed practice had the potential to affect 48 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to review and revise the care plan to reflect the focus, goals, and interventions for 1 (Resident #38) of 1 sampled residents that had been admitted to hospice services, for 1 (Resident #36) of the 8 (#1, #2, #5, #24, #31, #36, #41, #46) sampled residents that had a diagnosis of Schizoaffective Disorder, and for 1 (Resident #44) of 10 (#1, #2 , #5, #24, #31, #32, #36, #41, #44, #46) sampled residents who had an Antipsychotic Prescribed. 1. Resident #38 had diagnoses of Type 2 Diabetes Mellitus without Complications, Hypothyroidism, Unspecified Atrial Fibrillation, Metabolic Encephalopathy, Dysphagia. The Significate Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/1/22 documented a Brief Interview for Mental Status (BIMS) of 3 (0-7 indicates severely impaired). a. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to Develop and implement Person-Centered Care Plans that included and support the dementia care needs of a resident with a Dementia diagnosis for 1 (Resident #44) of 2 (Resident #38 and Resident #44) sampled residents. This failed practice had the potential to affect 6 resident's that had diagnoses of Dementia and resided in the facility per a list provided by the Administrator on 10/26/22 at 3:30pm.

Inspectors wroteBased on record review and interview, the facility failed to ensure a written discharge summary was completed that included a recapitulation of the resident's stay that consisted of a concise summary of the stay, course of treatment for 1 (Resident #50) of 1 sampled residents who was discharged in the past 90 days. 1. Resident #50 had diagnoses of Unspecified Dementia with Behavioral Disturbance, Muscle weakness (generalized), Essential Primary Hypertension, Paroxysmal Atrial Fibrillation. The Significate Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/22 documented a Brief Interview for Mental Status (BIMS) of 2 (0-7 Indicates Severely Impaired.) a. On 10/26/22 at 10:32 a.m., the Discharge Return Anticipated MDS with an ARD of 09/07/22 documented Resident #50 was discharged to another nursing home or swing bed. b. [...]