Inspection Reports for
Blossom Health Care Center Inc
989 Blossom Road, Rochester, NY, 14610
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
318% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Oct 1, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 09/25/2024 to 10/01/2024 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to timely report suspected abuse, inadequate investigation of alleged violations, failure to provide ordered wound care, lack of appropriate care for residents with limited mobility, absence of physician orders and care plans for oxygen use, improper storage of controlled medications, lack of policy and procedures for food brought by visitors, non-compliance with carbon monoxide detector testing requirements, and non-functional handwashing sinks in soiled utility rooms.
Deficiencies (9)
F 0609: The facility failed to timely report suspected abuse and did not report an incident where Resident #29 fell out of bed sustaining a major injury.
F 0610: The facility did not thoroughly investigate alleged violations involving abuse, neglect, or mistreatment related to Resident #29's fall with major injury.
F 0686: Resident #53 did not receive prescribed treatment for multiple stage three pressure ulcers due to unavailable ordered wound care supplies.
F 0688: Resident #3 did not consistently receive a hand device for a hand contracture as ordered, risking skin breakdown and limited range of motion.
F 0695: Resident #29 was observed using oxygen without a physician's order or a comprehensive care plan addressing respiratory needs.
F 0761: Controlled medications were not properly double-locked in medication cabinets on the second and third floors, compromising drug security.
F 0813: The facility lacked a policy and procedure for labeling, dating, and reheating foods brought by visitors, and staff were not trained or equipped to safely handle such foods.
F 0836: The facility did not comply with state fire code requirements for carbon monoxide detection and testing in areas with fuel-burning appliances.
F 0908: Handwashing sinks in the soiled utility rooms on the second and third floors were non-functional and did not discharge water when tested.
Report Facts
Dates of survey: 2024-09-25 to 2024-10-01
Incident date: Sep 11, 2024
Oxygen liters per minute: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Notified of Resident #29 fall and provided statements |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Involved in Resident #29 fall incident and statements |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Resident #29's primary CNA and provided statements |
| Director of Nursing | Director of Nursing | Provided interviews regarding Resident #29 fall and oxygen use |
| Registered Nurse Manager #1 | Registered Nurse Manager | Conducted investigation and provided interviews |
| Registered Nurse #2 | Registered Nurse | Applied wound care and provided interviews |
| Pharmacist #1 | Pharmacist | Provided information on wound care cream availability |
| Physician #1 | Physician | Ordered wound care and provided interviews |
| Registered Nurse #3 | Registered Nurse | Performed wound rounds and provided interviews |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Provided information on Resident #3 hand device care |
| Physical Therapist #1 | Physical Therapist | Provided therapy recommendations for Resident #3 |
| Registered Nurse #1 | Registered Nurse | Observed medication cabinet issues and provided interviews |
| Licensed Practical Nurse Manager #1 | Licensed Practical Nurse Manager | Provided information on medication cabinet security |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Provided information on medication cabinet and food labeling |
| Director of Maintenance | Director of Maintenance | Provided information on medication cabinet locks and CO detectors |
| Food Service Director | Food Service Director | Provided information on food labeling and reheating policies |
| Certified Nursing Aide #5 | Certified Nursing Aide | Provided information on food labeling and reheating |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Oct 1, 2024
Visit Reason
Complaint Survey with 10 health and 6 life safety citations, all corrected by November 2024. Deficiencies included essential equipment, infection control, medication labeling, and life safety code issues such as corridor doors and emergency lighting.
Findings
Complaint Survey with 10 health and 6 life safety citations, all corrected by November 2024. Deficiencies included essential equipment, infection control, medication labeling, and life safety code issues such as corridor doors and emergency lighting.
Deficiencies (16)
Essential equipment, safe operating condition
Increase/prevent decrease in rom/mobility
Infection control
Investigate/prevent/correct alleged violation
Label/store drugs and biologicals
License/comply w/ fed/state/locl law/prof std
Personal food policy
Reporting of alleged violations
Respiratory/tracheostomy care and suctioning
Treatment/svcs to prevent/heal pressure ulcer
Corridor - doors
Electrical systems - essential electric syste
Emergency lighting
Fire alarm system - testing and maintenance
Patient sleeping room doors
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
The inspection was conducted as a Recertification Survey combined with a complaint investigation regarding wound care for Resident #53.
Complaint Details
The complaint investigation was substantiated, revealing that Resident #53 did not receive necessary wound care treatments as ordered by the physician, due to unavailable medication and failure to enter new orders into the electronic health record.
Findings
The facility failed to provide prescribed wound care treatments to Resident #53, including the administration of Triad Hydrophilic cream and timely implementation of new physician orders. Documentation and communication lapses contributed to the resident not receiving appropriate pressure ulcer care.
Deficiencies (1)
F 0686: The facility did not ensure Resident #53 received prescribed treatment for multiple stage three pressure ulcers, including failure to administer Triad Hydrophilic cream and to implement new wound care orders timely.
Report Facts
Residents Affected: 1
Dates of wound care non-compliance: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Interviewed regarding unavailability of Triad Hydrophilic cream and wound care application | |
| Registered Nurse Manager #1 | Interviewed about medication order processes and unawareness of wound care medication issues | |
| Pharmacist #1 | Interviewed about pharmacy stock and provision of Triad Hydrophilic cream | |
| Physician #1 | Provided wound care orders and commented on timely implementation expectations | |
| Registered Nurse #3 | Performed weekly wound rounds and discussed wound care supply availability | |
| Director of Nursing | Discussed wound care supply ordering and communication procedures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Feb 16, 2023
Visit Reason
Complaint Survey with 3 health citations related to medication errors, nursing staff sufficiency, and resident care, all corrected by March 2023.
Findings
Complaint Survey with 3 health citations related to medication errors, nursing staff sufficiency, and resident care, all corrected by March 2023.
Deficiencies (3)
Residents are free of significant med errors
Rn 8 hrs/7 days/wk, full time don
Sufficient nursing staff
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Dec 5, 2022
Visit Reason
Recertification survey and complaint investigations to assess compliance with state and federal nursing facility regulations.
Complaint Details
Complaint investigations (#NY00291558, #NY00291712, #NY00297274, #NY00287526, #NY00297130) were conducted alongside the recertification survey, revealing multiple deficiencies including wound care, incontinence care, nurse call system failures, and transportation safety issues.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs for call bells, incomplete notification of transfer/discharge and bed-hold policies, inadequate PASARR screening, incomplete wound care documentation, delayed incontinence care, lack of audiology evaluation for a hard of hearing resident, unsafe transportation practices, inconsistent tube feeding documentation, incomplete nurse staffing postings, improper narcotic reconciliation, malfunctioning elevator and laundry equipment, and non-functioning nurse call systems.
Deficiencies (15)
F 0558: The facility did not ensure residents received services with reasonable accommodation of needs; Resident #13 was not provided a call bell suited to their functional needs and the call bell was out of reach.
F 0575: The facility did not post contact information for the NYSDOH complaint hotline and Ombudsman in accessible locations on resident floors.
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment; issues included broken furniture, stained floors and sinks, malfunctioning bed controls, dirty kitchen equipment, and non-working exhaust ventilation.
F 0623: The facility failed to provide timely written notification of transfer/discharge to residents or their representatives for two residents hospitalized during the survey period.
F 0625: The facility failed to provide written notification of the bed-hold policy to residents or their representatives at the time of hospital transfer for two residents.
F 0645: The facility did not ensure PASARR screening was completed or was incomplete for two residents with mental illness diagnoses.
F 0658: The facility did not ensure wound care treatments were administered and documented as ordered for two residents with pressure ulcers and wounds.
F 0677: The facility did not provide timely incontinence care for Resident #53, resulting in prolonged exposure to moisture and reddened skin.
F 0685: The facility did not ensure Resident #28 received an audiology evaluation despite documented hearing impairment and communication difficulties.
F 0689: The facility did not ensure a nursing home area was free from accident hazards; Resident #332 slid out of a wheelchair during transport due to lack of a lap belt in the vehicle.
F 0693: The facility did not consistently monitor and document the accurate amount of tube feeding and free water administered to Resident #34 as ordered, contributing to hospital readmissions for hypernatremia.
F 0732: The facility did not post daily nurse staffing information in a prominent, accessible location and included non-care staff in the assistant/tech count.
F 0755: The facility did not maintain accurate reconciliation of controlled substances; narcotic count sheets had missing dates, times, signatures, and counts on multiple shifts.
F 0908: The facility did not maintain all mechanical and patient care equipment in safe operating condition; one elevator was out of service since July 2022 and two laundry dryers were non-functional for 4-5 months.
F 0919: The facility did not maintain a working nurse call system; multiple call stations on the second and third floors did not activate lights or signals and repairs were not documented.
Report Facts
Opportunities for wound treatment documentation missed: 22
Opportunities for wound treatment documentation missed: 18
Tube feeding documentation incomplete: 7
Free water documentation incomplete: 47
Narcotic count sheet missing entries: multiple
Elevator out of service duration: 5
Laundry dryers out of service duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in narcotic count and wound care documentation findings. |
| Licensed Practical Nurse #2 | LPN | Named in narcotic count findings. |
| Certified Nursing Assistant #1 | CNA | Named in call bell and incontinence care findings. |
| Certified Nursing Assistant #2 | CNA | Named in hearing impairment and call bell findings. |
| Director of Nursing | DON | Named in multiple findings including wound care, narcotic counts, call bell, and transportation safety. |
| Director of Social Work | DSW | Named in transfer/discharge notification and PASARR findings. |
| Director of Admissions | Director of Admissions | Named in bed-hold notification findings. |
| Corporate Registered Nurse | CRRN | Named in wound care documentation findings. |
| Corporate Engineering Coordinator | CEC | Named in elevator and nurse call system maintenance findings. |
| Director of Food Service | DFS | Named in kitchen cleanliness findings. |
| Regional Corporate Dietician | RCD | Named in tube feeding documentation findings. |
| Licensed Practical Nurse / Nurse Manager | LPN/NM | Named in tube feeding documentation findings. |
| Driver | Facility Driver | Named in transportation safety findings. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 29
Date: Dec 5, 2022
Visit Reason
Complaint Survey with 16 health and 13 life safety citations including deficiencies in ADL care, equipment safety, environment, staffing information, and fire safety, all corrected by early 2023.
Findings
Complaint Survey with 16 health and 13 life safety citations including deficiencies in ADL care, equipment safety, environment, staffing information, and fire safety, all corrected by early 2023.
Deficiencies (29)
ADL care provided for dependent residents
Essential equipment, safe operating condition
Free of accident hazards/supervision/devices
Notice of bed hold policy before/upon trnsfr
Notice requirements before transfer/discharge
Pasarr screening for md & id
Pharmacy srvcs/procedures/pharmacist/records
Physical environment
Posted nurse staffing information
Reasonable accommodations needs/preferences
Required postings
Resident call system
Safe/clean/comfortable/homelike environment
Services provided meet professional standards
Treatment/devices to maintain hearing/vision
Tube feeding mgmt/restore eating skills
Aisle, corridor, or ramp width
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Elevators
Emergency lighting
Ep training and testing
Ep training program
Fire alarm system - testing and maintenance
Fire drills
Hvac
Maintenance, inspection & testing - doors
Other laws, codes, rules and regulations.
Utilities - gas and electric
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 28, 2022
Visit Reason
Complaint Survey with 1 health citation related to notification of changes in resident condition, corrected by September 2022.
Findings
Complaint Survey with 1 health citation related to notification of changes in resident condition, corrected by September 2022.
Deficiencies (1)
Notify of changes (injury/decline/room, etc. )
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Nov 6, 2020
Visit Reason
The inspection was a Recertification Survey including a Complaint Investigation to assess compliance with regulatory requirements for nursing home care.
Complaint Details
The complaint investigation (#NY00260114) found the facility failed to thoroughly investigate alleged abuse for two residents, including lack of documentation and follow-up on reported incidents.
Findings
The facility was found deficient in multiple areas including resident participation in care planning, investigation of abuse allegations, development and implementation of comprehensive care plans, feeding tube management, dialysis care, psychotropic medication management, dietetic services, menu preparation, infection prevention and control, and antibiotic stewardship.
Deficiencies (11)
F 0553: The facility did not ensure residents or their representatives were given the right to participate in interdisciplinary care plan meetings during the Recertification Survey.
F 0610: The facility failed to thoroughly investigate alleged abuse for two residents, lacking documentation and follow-up.
F 0656: The facility did not develop and implement complete person-centered care plans for three residents, including failure to ensure compression stockings and palm protectors were used and lack of interventions for accident hazards.
F 0693: The facility did not provide appropriate treatment and monitoring for a resident with a feeding tube, including inaccurate documentation and failure to clarify physician orders.
F 0698: The facility failed to ensure dialysis residents received care consistent with professional standards, specifically lacking consistent monitoring of fluid intake per physician orders.
F 0758: The facility did not ensure gradual dose reductions or attempts to reduce unnecessary psychotropic medications for a resident on antidepressants.
F 0801: The facility did not employ a qualified dietician to carry out food and nutrition services, with the consultant dietician working remotely and no physical nutritional assessments completed.
F 0803: The facility did not follow recipes for modified consistency diets, failing to weigh cooked chicken and not using the prescribed recipe for pureed meat.
F 0880: The facility failed to establish and maintain an Infection Prevention and Control Program that consistently tracked, investigated, and analyzed infection surveillance data.
F 0881: The facility did not implement an Antibiotic Stewardship Program and lacked documentation and monitoring of antibiotic use.
F 0882: The facility did not designate a qualified Infection Preventionist with specialized training responsible for the Infection Prevention and Control Program.
Report Facts
Residents reviewed: 23
Residents reviewed: 42
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 8
Infection control tracking gap: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in feeding tube fluid administration error |
| Director of Nursing | Director of Nursing | Named in multiple findings including care plan, feeding tube, dialysis, infection control |
| Social Worker | Social Worker | Named in care planning meeting participation deficiency |
| Administrator | Administrator | Named in abuse investigation deficiency and infection control program |
| Consultant Pharmacist | Consultant Pharmacist | Named in psychotropic medication management deficiency |
| Registered Dietician | Registered Dietician | Named in dietetic services and menu preparation deficiencies |
| Dietetic Service Supervisor | Dietetic Service Supervisor | Named in dietetic services and menu preparation deficiencies |
| Chef | Chef | Named in menu preparation deficiency |
| Director of Social Work | Director of Social Work | Named in abuse investigation deficiency |
| Nurse Practitioner | Nurse Practitioner | Named in psychotropic medication management deficiency |
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