White Blossom Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate and safe discharge process for one of three residents (Resident 1) when:1. Failure to provide the Notice of Proposed Transfer/Discharge as soon as practicable before the discharge;2. Failure to assess and identify Resident 1's living situation; and3. Failure to coordinate and confirm home health services. These failures resulted in Resident 1 being discharged without a confirmed discharge destination and follow-up services, placing the resident at risk for unmet medical needs, interruption in care, and harm. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to promote the patient rights for one of five residents (Resident 2). This failure had the potential to negatively affect Resident 2's psychosocial wellbeing and sense of security.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation during storing and preparing food in accordance with professional standards for food service safety when:Three of three ice machines (one in kitchen, and two located in nursing station areas) were not clean. The strength of sanitizer used to sanitize a kitchen food preparation table was not an appropriate strength. A kitchen industrial can opener and its base were not clean. These failures had the potential to increase the risk of food contamination to the residents in the facility for 147 residents who ate food by mouth out of a facility census of 153.1. During a concurrent observation and interview on 3/10/26 at 10:03 a.m. with the Maintenance Supervisor (MS) in the kitchen, the ice machine was observed. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow their policy and procedure regarding foods brought to residents by family and visitors when the facility did not educate family and visitors to prepare and transport food using safe handling practices outlined in the policy and procedure. This failure increased the risk of family members bringing contaminated food to residents leading to food born illness for 147 who ate food by mouth out of a census of 153. Review of the undated policy and procedure titled Foods Brought by Family/Visitors, showed family/visitors are asked to prepare and transport food using safe food handling practices, including: safe cooling and reheating processes, holding temperatures, preventing cross-contamination with raw or undercooked foods, and hand hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary environment for residents and staff when:Cloth straps used to hold ice chests were not clean. The floor around a metal cabinet in the kitchen was not clean, and the floor in the kitchen walk-in freezer was not clean. A kitchen's air conditioner surface was not clean. A large portion of paint was detached from the wall surface in the kitchen. The baseboard around the kitchen trayline table in the kitchen was broken and cracked. The vent in the kitchen's chemical room was not clean. There was no air gap for the kitchen food preparation sink drain. These failures had the potential to provide harborage for pests and/or contaminate equipment leading to contamination of food for 147 residents out of a census of 153.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dialysis services consistently with professional standards and to ensure staff had coordinated residents' care with the dialysis center for three of five sampled residents (Residents 73, Resident 42, and Resident 99) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e., salts and mineral imbalances by using a machine and an artificial kidney) when:Inaccurate access site assessment information and communication with the facility to dialysis center prior (Pre) - Hemodialysis Communication/assessment Records (HCAR's) to dialysis treatment and after (Post) dialysis treatment; [...]

Inspectors wroteBased on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis, especially on the weekend based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect resident's care, health, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff had appropriate competencies when:Two of two kitchen staff (The Dietary Manager, Dietary Aide B) did not follow manufacturer's instructions for sanitizer test strips when testing the strength of the sanitizer used to clean the food contact surfaces in the kitchen. Three of three staff (The Registered Dietitian, the Dietary Manager, and [NAME] A) did not know and/or follow instructions for fortifying diets. The failure to ensure staff competency for testing sanitizer strength had the potential to increase the risk of food contamination to residents, and the failure to ensure staff competency for fortifying diets had the potential to result in decreased calorie intake for residents receiving a fortified diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. The Licensed Nurse did not establish a sterile field on the overbed table prior to performing the PICC line (a long, flexible tube inserted through a peripheral arm vein and advanced into a large vein near the heart) dressing change for Resident 7.2. Resident 73's unlabeled nebulizer mask (plastic mask and tubing used as a connection from compressor to deliver mist to client )that was attached to the machine was exposed and touching the bedside table and nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration) was hanging at the side of his wheelchair and the two prongs were touching the floor;3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain respect and dignity for four of five sampled residents (Residents 17, 167, 28, and 7) when:1. Registered nurse F (RN F) was standing while feeding Resident 17 in bed, near the room's opened door;2. Resident 167's care instructions were posted above Resident 167's head of bed's wall uncovered; and,3. Resident 28 did not have a covering bag to conceal his drainage bag; and,4. The Licensed Nurse wrote her initials and the date on the tape while it was on Resident 7's arm during dressing change. These failures had the potential to negatively affect resident's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, for one of two sampled residents (Resident 158), the facility failed to inform the Responsible Party (RP- person legally responsible to make decisions for a resident) regarding plan of care and/or treatment changes when Resident 158's RP was not informed of physician ordered laboratory tests involving a procedure to obtain a urinary sample. This failure resulted in Resident 158's Responsible Party to unaware of Resident 158's test and procedure for obtaining the urine sample. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely administer medication for one of thirty sampled residents (Resident 108) when licensed vocational nurse I (LVN I) left three routine medications on Resident 108's overbed table unattended, for self-administration. These failures had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive, individualized, resident-centered care plans for two of 30 sampled residents (Residents 105, and 13) when:1. Resident 105's care plan for diagnosis of alcohol dependence with alcohol induced persisting dementia (a form of permanent brain damage caused by long-term, heavy alcohol consumption) since 1/15/2026, with brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 08 (a score of 00 to 07 indicates severe cognitive impairment, 08-12 moderate impairment, 13-15 patient is cognitively intact) was not developed; and2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide services according to professional standards for one of 30 sampled residents (Resident 15) when the speech language pathology (SLP) evaluation and treatment order was not carried out. This failure had the potential to affect Resident 15's care, health, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 30 sampled residents (Residents 40) were free from unnecessary medication when Resident 40 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) for edema not indicating the specific site of edema and there were no monitoring for the nursing staff to monitor the edema. This deficient practice resulted in unmonitored medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and maintenance of one out of two medication refrigerators, when1. A thermometer was not present inside the medication refrigerator, and the internal light did not function when the refrigerator door was opened; and,2. Resident 90's medication was not removed from active stock in the medication refrigerator for nine days after the resident expired. These deficient practices had the potential to result in residents receiving medications with reduced potency, as well as medication errors due to failure to remove discontinued medications from active stock.

Inspectors wroteBased on observation, interview, and document review, the facility failed to offer provide a substitute of similar nutritional value for a menu item (milk), when Resident 133 preferred not to have milk at lunch meals. The failure to provide a substitute item of similar nutritional value had the potential to result in Resident 133 not receiving the nutrients meant to be provided by the planned menu leading to an inadequate nutrient intake. The menu spreadsheet titled Spring Cycle Menus dated 3/11/26, showed 8 ounces of milk on the menu for the Regular diet. During an observation in the resident dining room on 3/11/26 at 12:51 p.m., Resident 133 sat at a table eating her facility provided lunch. For her beverage, Resident 133 had one cup of juice in front of her. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure supervision was provided for one of three residents (Resident 1) when Resident 1 was left in the hallway unattended. This failure resulted to Resident 1 falling from her wheelchair. Resident1 sustained abrasion in the left elbow.

Inspectors wroteBased on interview and record reviews, the facility failed to provide the necessary care and services for two of 3 sampled residents (Residents 1 and 2) when: 1. Facility staff did not ensure timely assessment, physician notification, or complete documentation of a change in condition for Resident 1; and 2. Facility staff did not notify the physician or conduct a thorough investigation after Resident 2 fell on 2/27/25. These failures placed Residents 1 and 2 at risk for delayed treatment and potential harm.

Inspectors wroteBased on interview and record review, the facility failed to provide services in accordance with professional standards of practice for one of two sampled residents (Resident 1) when license nurses did not accurately complete Resident 1's elopement and wandering risk assessment. This failure had the potential to compromise the facility's ability to provide resident-centered interventions based on assessment data.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was updated to reflect a newly diagnosed serious mental disorder for 1 (Resident #11) of 6 residents reviewed for PASRR requirements.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) Level I screenings accurately reflected the presence of diagnosed serious mental disorders and failed to ensure new PASRR Level I screenings were submitted on the 31st day of admission to the skilled nursing facility following an exempted hospital discharge for 2 (Resident #127 and Resident #25) of 6 residents reviewed for PASRR requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Eight plastic containers of [brand name] bleach (provide effective infection control for hard surfaces to help stop pathogen transmission) lids were not closed and were exposed in the hallways; 2. Two certified nursing assistants A and B (CNA A and CNA B) were wearing gloves in the hallway walking room to room and did not perform hand hygiene in between task; 3. One box of clean gloves and one bottle of hand sanitizer were on top of a clean movable cart and were approximately 1/2 inch from a treatment cart with attached trash bin with an open lid. 4. Three laundry hampers with three linens on top were stored outside by the facility patio; 5. A bin was over flowing with housekeeping towels outside the laundry area hallway; 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 2) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions, and behavior) when Resident 2 received quetiapine fumarate (Seroquel, an antipsychotic medication used to treat certain mental/mood conditions) without adequate indication and monitoring a specific target behavior for its use. This failure could result in lack of adequate monitoring and had the potential for residents to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for one of four residents (Resident 1) when the door of the Covid-19 isolation room was open. This failure had the potential to result in transmission and spread of Covid-19 infection.

Inspectors wroteBased observation, interview, and record review the facility failed to implement infection control practices for three of four emergency crash carts when: 1. Emergency crash carts (crash cart is a set of trays/drawers/shelves on wheels used for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols to potentially save someone's life) B, and C contained oropharyngeal airway (OPA, also known as an oral airway is a medical device that helps maintain or keep a patient's airway open) kit that was not stored in the original packaging and was not labeled with shelf-life expectancy or no expiration date. 2. Emergency crash cart A contained oropharyngeal airway kit stored in two plastic bags had yellowish substance with no label or expiration date. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform a thorough investigation and report for seven of nine residents (Residents 1, 2, 3, 4, 5, 11, and 12). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three resident (Residents 8, 9, and 10) were kept free from constipation when physicians orders were not followed for interventions according to the facility's policy and professional standards. This failure caused each resident to become unnecessarily constipated.

Inspectors wroteBased on interview and record review, the Social Service Director (SSD) failed to inform the responsible party (RP, person designated to make decisions on behalf of a resident) of one of two sampled residents (Resident 1) regarding Resident 1's appointment with a psychologist. This failure had the potential to affect the ability of the RP to participate in Resident 1's treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three Residents (Resident 1) when space heater was used in the rehabilitation room. This failure had the potential to compromise residents' safety, health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe smoking environment and provide supervision for nine of nine residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) who smoked outside of the facility as evidenced by: 1. The facility failed to follow the Minimum Data Set (MDS, a standardized assessment tool for residents' functional status to help identify health problems and to identify the proper care needed) assessment to provide staff supervision and/or physical assistance for nine of nine residents (Residents 1,2,3,4,5,6,7,8 and 9) when these nine residents left their rooms/units and went outside of the facility to smoke at the old smoking area, located at the corner of the facility near a major street and the facility's parking lot. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure staff followed their fall policy for one of three sampled residents (Resident 1). Resident 1 fell six times within a month and the interdisciplinary team (IDT, members of the health care team who meet to discuss and plan residents' care) did not meet after every fall, comprehensive post fall assessments were not always conducted and post fall care plans were not consistently updated with preventative measures. This failure placed the resident at risk for further falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to follow their room change policy for one of three sampled residents (Resident 1) when there was no documentation that the responsible party (RP, person designated to make decisions on behalf of the resident) was notified of multiple room changes. There was also no documentation that the facility monitored Resident 1 after these room changes occurred. These failures had the potential to compromise Resident 1's rights and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for 5 of 29 sampled residents (Residents 44, 91, 122, 493, 496 and 512). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure seven of 29 sampled residents (Residents 1, 13, 19, 23, 35, 37 and 442) had a Baseline care plan within 48 hours of resident's' admission when residents' Baseline care plan were incomplete. These failures had the potential for the facility staff not to meet the residents' immediate care needs and safety against adverse events that most likely to occur right after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted; and medications were available to administer or given according to the physician's order/manufacturer's specifications, when: 1. Three out of four nurses failed to document on the controlled substance accountability sheet (aka Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) in a timely manner after they removed the medications from the medication carts; 2. Norco (a potent narcotic for pain) 10/325 milligrams (mg, unit of measurement) for Resident 90 was given too soon before it was due and not according to the physician's order; 3. Random controlled medication use audit for six of six residents (Residents 11, 21, 57, 89, 107, and 503) did not reconcile. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of 29 sampled residents (Residents 1, 37, and 55) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 37 received Abilify (an antipsychotic medication) when there was no clinical indication; 2. Resident 55 received Seroquel (an antipsychotic medication) without adequate indication for its use or documented evidence of target symptoms resulting harm or severe distress to the resident; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Temperature monitoring was not consistently documented twice daily on the temperature log sheets, in November 2021 and January 2022, for two of three medication refrigerators (REF #1 and REF#2); 2. An prescription eye medication and five insulin pens did not have the pharmacy labels; 3. Three inhalers were not dated after being opened in Medication Cart #1A; 4. An insulin vial and an oral inhaler were identified in the active stock, being used beyond the discard (expiration) date; and 5. An insulin dispensed and labeled for Resident 52 was being used for Resident 71. The deficient practices had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Kitchen refrigerator's wire rack had yellowish to orange color; 2. Spatula was chipped; 3. Seven pans were stacked and not air dried; 4. Knife sharpener had tape; 5. Measuring scoop had brownish color 6. Microwave's plastic film was peeling off and had accumulation of orange particles; 7. Can opener gear had orange to brownish color; 8. Station X's ice machine bin had whitish to brownish buildup and Station XYZ ice machine had whitish and greenish discoloration; 9. Two cutting boards had deep cuts; 10. Food in the residents refrigerator was not labeled; and 11. Refrigerator temperature for residents' food were not monitored consistently. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Laboratory staff (LS) was not properly screened before entering the facility; 2. Mortuary Staff (MS) was not wearing N95 (a high filtering mask) and did not gown up; 3. Certified nursing assistant R (CNA R) was not wearing N95; 4. Infection Preventionist (IP) was not wearing N95 properly; 5. Licensed vocational nurse C (LVN C) did not perform hand hygiene and change gloves after touching potentially contaminated surfaces during the medication administration for Resident 71. These failures could result in the spread of infection and cross-contamination that could affect the 148 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 29 sampled residents (Residents 89 and 243) who kept medications at bedside had a physician order, care plan and an assessment as capable of self-administering medication. These failures had the potential to result in unsafe medication administration and could have allowed other residents to access unlocked medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs were accommodated for three residents (35, 55, and 72) when the call light devices were not within reach. This failure had the potential for a delayed response and not meeting the resident needs.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for three of 29 sampled residents (Residents 91, 496, and 507). This failure had the potential to put the residents at risk for not receiving appropriate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for two of 29 sampled residents (Residents 37 and 43 ) and 2 non-sampled residents (Residents 55 and 125) when: 1. For Resident 125 intravenous solution and intravenous tubing were not dated; 2. For Resident 43, bruise was not monitored; 3. For Resident 37, oxygen was administered without a physician's order; 4. For Resident 55, oxygen was not administered as ordered. These failures had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 29 sampled residents (Residents 242, 6, and 52) when: 1. Resident 242's intervention to have psych consult was not implemented and her care plan was not person-centered; 2. Resident 6's care plan for non-compliance with fluid restriction was not initiated. 3. Resident 52's care plan for heparin (blood thinner to treat or prevent blood clots) and furosemide (water pill) use were not initiated. These failures had the potential to compromise the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 29 sampled residents (Resident 501), when there was no admission skin assessment completed and the licensed nurse did not obtain measurements when facility aquired pressure ulcers were identified on the bilateral heels and mid-back of Resident 501. These failures had the potential to delay treatments and potentially lead to new or worsening pressure ulcers. Failure to obtain measurements had the potential to compromise the facility's ability to determine whether Resident 501's pressure ulcers were increasing or decreasing in size.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate treatment and services were provided for one of 29 sampled residents (Resident 91) when the restorative nursing assistant (RNA, program that helps residents to gain and improve quality of life by increasing their level of strength and mobility) program was not implemented. The deficient practice had the potential to result in residents' decline in range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure non smoking policy and fall management policy were implemented to prevent accident for three of 29 sampled residents (Residents 90, 128, and 130) when: 1. The interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) failed to do a proper smoking risk assessment, provide adequate monitoring and failed to revised Resident 90's smoking care plan. 2. Resident 128 did not have a post fall assessment, fall care plan was not updated and IDT was not done; and 3. Resident 130's neurological assessment (neuro checks, an assessment of neurological functions and level of consciousness) was incomplete. These failures had the potential to result in serious injury to the residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of 29 sampled residents (Resident 43) when his dialysis communication reports (DCR) were incomplete. This deficient practice had the potential for Resident 43's dialysis care not being properly communicated and could put Resident 43 at risk for complications.