The Blossoms at Woodland Hills Rehab & Nursing Cen

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from neglect. Specifically, the facility failed to obtain a urine sample in a timely manner to rule out a Urinary Tract Infection (UTI) for Resident #1 and failure to order an antibiotic in a timely manner for Resident #1 to treat a UTIIt was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to eCFR S483.12(Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K.The IJ began on [DATE] at 6:02 PM, when Resident #1 had a written physician order to obtain a Urinary Analysis (UA) to rule out a UTI. On [DATE] at 6:06 PM, according to a lab report, resident's urine sample was obtained. [...]

Inspectors wroteBased on observations, interviews, and facility document review, it was determined that the facility failed to ensure a Licensed Practical Nurse (LPN) held an active and unencumbered license while working in the facility as an LPN. Based on interviews, facility document review, and facility policy reviews, it was determined that the facility failed to ensure a Licensed Practical Nurse (LPN) held an active and unencumbered license while working in the facility as an LPN.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide nail care for one (Resident #6) of three residents reviewed for nail care, and to ensure staff answered one (Resident #8) of four resident ' s call lights in a timely manner.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that cross contamination did not occur during lunch service for one of one kitchen observed.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that residents were living a dignified existence for two residents (Resident #6 and Resident #67) of two sampled residents reviewed for dignity.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADL) care such as facial hair removal, and nail care were completed for two (Resident #6 and Resident #67) of five sampled residents reviewed for ADL care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure cigarettes and lighters were properly stored, to prevent residents from having and using cigarettes and lighters without staff knowledge, on 1 of 1 observation, to prevent accidental burns and injury. This failed practice had the potential to affect 4 (Resident #29, #40, #61, and #84) of 18 sampled residents, reviewed for smoking tobacco or nicotine use to ensure safe interventions were in place. The facility also failed to ensure 1 resident (Resident #59) of 1 sampled resident was not in the smoking area with cigarettes and lighter stored in a personal cigarette case to prevent possible injury.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure three (3) syringes of [Name Brand Anti-anxiety medication] were documented in a narcotic book to maintain receipt and accounting of a narcotic during 1 of 1 observation to prevent diversion for 1 (Resident #71) resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that medications were locked away and stored in a manner that prevented resident access for 1 of 1 observation of the central supply room. Specifically, a box of medications was found resting on a pallet in central supply and the doorknob was broken. The door was ajar and could not be closed. The facility failed to ensure 13 bottles of expired [name brand] supplemental feeding were removed from the supply shelf to prevent nursing staff from using them on residents with feeding tubes for 1 of 1 observation.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 (Resident #1, Resident #2, Resident #3, Resident #4) of 4 sampled residents reviewed of physical environment.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure kitchen ceiling tiles, air vents, walls, storage racks, exhaustion fan, and garbage disposal were cleaned, door frames were free of chips, and dietary staff thoroughly washed their hands and changed gloves when contaminated, before handling food and clean equipment for 2 of 2 meals observed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure personal care including bathing and toenail care was provided for residents that required activity of daily living (ADL) assistance to promote good hygiene and prevent infections. This failed practice affected 1 sampled (Resident #11) resident of 2 sampled (Resident #10, and Resident #11) residents reviewed for personal care.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the refrigerator and storage area were covered or sealed to maintain freshness and prevent potential cross contamination of food and beverages; expired food items were promptly removed/discarded by the expiration or use by dates; kitchen vents were cleaned to provide a sanitary environment for food preparation; floors, kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, debris, rust, and dirt; 2 of 2 ice scoop holders, and 1 of 2 ice machines were maintained in clean and sanitary condition to prevent food and beverages contamination; and hot food items were maintained at or above 135 degrees Fahrenheit while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner to ensure residents requests for assistance were addressed promptly for 2 (Residents #24 and 41) of 2 sampled residents whose call lights were activated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the smoking area outside of the dayroom for Halls E through H was safe to utilize for smoking for 1 (Resident #24) of 7 (Residents #4, #7, #18, #24, #30, #38 and #43) sampled residents who utilized the smoking area outside of the dayroom for Halls E through H; the facility failed to ensure that nail trimmers were not stored in residents room or within easy reach of the resident or other residents to prevent possible harm. This failed practice affected 1 (Resident #4) of 14 (Residents #18, #38, #43, #12, #47, #46, #30, #14, #44, #33, #31, #7, #63) sampled residents who ambulate or self-propel in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oxygen was administered only under the direction of a Physician's order for 1 (Resident #41); proper signage was posted outside the room pertaining to the use of oxygen for 2 (Residents #41 and #46); and the oxygen concentrator was free of debris for 1 (Resident #46) of 2 sampled residents who were receiving oxygen.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the refrigerated narcotic medications in the medication storage room across from the nursing station for Halls A, B, C and D were stored in a permanently affixed compartment for 1 of 1 medication storage room to prevent the potential of misappropriation of resident property, and failed to ensure no medication was remaining in the chamber of a nebulizer to decrease the potential for health complications 1 (Resident #226) of 1 sampled resident who had physician orders for an updraft treatment.

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 2 of 2 meals observed. The failed practice had the potential to affect 31 residents who received meal trays in their rooms on the A, B, and C, Hall, 18 residents who received their meal trays in the room on the D, E and F Hall (Back) Hall, as documented on a list provided by the Regional Dietary Manager.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the grounds of the smoking area outside of the dayroom for halls E through H was cleared of smoking remnants and the receptacles used to collect the smoking remnants were emptied after use to promote a clean and healthy environment for 1 (Resident #24) of 7 sampled residents who utilized the area outside of the dayroom to smoke as documented on a list provided by the Administrator; and failed to ensure a resident's environment was functional and sanitary for 1 (Resident #7) of 1 sampled resident who had a sheet with unknown substances wrapped around the plumbing under the sink.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman as required for 1 (Resident #46) of 6 (Residents #2, #5, #46, #72, #74, and #275) sampled residents who were transferred to the hospital in the last month.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Quarterly Minimum Data Set (MDS) was transmitted in a timely manner to promote individualized care for 1 (Resident #33) of 66 (All Residents, Census: 66) residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were reviewed and revised at least quarterly and/or when residents' care needs changed, as evidenced by failure to revise the plan of care to address the use of insulin, a high-risk medication, to ensure staff were aware of the necessary care, assessments and services required for 1 (Resident #24) of 1 sampled resident who had orders for insulin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was consistently provided to promote good grooming and personal hygiene for 1 (Resident #17) of 1 sampled resident who required staff assistance with nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to minimize the potential for further decline in range of motion (ROM) for 1 (Resident #5) of 1 sampled resident who had limited range of motion.

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 2 of 2 meals observed. This failed practice had the potential to affect 1 resident who received pureed diets from 1 of 1 kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure handrails were in proper working order to prevent possible injuries to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident rights were honored on room placement. This failed practice had the potential to affect all 66 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grievances were filed and followed up on to meet the needs of the residents. This failed practice had the potential to affect all 66 residents that reside in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were securely stored in 2 of 4 medication carts. This failed practice had the potential to affect 27 self-mobile residents who resided in the facility on halls A through D and E through H, as documented on a list provided by the Director of Nursing (DON) on 01/09/2024 at 12:46 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure portable oxygen tanks were removed from a resident's room and placed in a secured locked area to prevent the potential of accidents and/or hazards for 1 (Resident #259) of 2 (Residents #259 and #260) sampled residents who had physicians orders for oxygen and failed to ensure an Ambu bag was at the bedside of a resident who relied on a tracheostomy to sustain life for 1 (Resident #260) of 2 (Residents #43 and #260) sampled residents who had a tracheostomy according to lists provided by the Director of Nursing (DON) on 11/30/22 at 2:00 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the urinary catheter tubing was maintained in a position below the level of the bladder and there was a device secured to the tubing to prevent the tubing from coiling underneath the buttocks and stump to prevent the potential for further skin breakdown and/or obstructed urine flow for 1 (Resident #157) of 3 (Residents #47, #157 and #260) sampled residents who had catheters. This failed practice had the potential to affect 4 residents in the facility with catheters according to the list provided by the Administrator on 12/01/2022 at 8:50 AM.