Inspection visit

InspectionMay 19, 2022

OHMAN FAMILY LIVING AT BLOSSOMCMS #3661248 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #36 received his meal at the same time as the other residents. This affected one of three residents (Resident's #28, #36 and #49) reviewed for dining. The facility census was 54. Finding include: Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses including Parkinson's disease, scoliosis, obsessive compulsive disorder, anxiety, and type II diabetes. Physician order dated 04/23/21 revealed Resident #36 received a regular diet, mechanical soft texture, thin consistency. Review of the Significant Change Minimum Data Summary (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired with fluctuating periods of inattention, required supervision and set-up only for eating, had a significant weight loss and an infection to his foot. Review of the care plan dated 04/18/22 revealed a care area for a nutritional problem or potential nutritional problem related to increased calorie/nutrient needs due to system inefficiency related to chronic disease (compromised cardiac function, Parkinson's, type II diabetes), infection healing/repletion needs and a history of artificial weight inflation due to fluid. Interventions included a preference of dining in the south dining room in a specific chair with a tray table or in his room, weight goal of 125 to 135 pounds (lbs.), providing, serving diet as ordered and recording meal intake. Review of the weights for Resident #36 revealed the most recent weight on 05/17/22 of 109.5 lbs., with a body mass index (BMI) of 18.8 and an ideal body weight of 140 to 169 lbs. Observation of lunch on 05/18/22 revealed Resident #36 entered the dining room at 12:04 P.M. All residents, except Resident #36 were served their meal by 12:31 P.M. At 12:33 P.M. servers began placing plates of food covered in foil at the seats where residents had not arrived, including tables near where Resident #36 was sitting. At 12:41 P.M. Dietary Personnel (DP) #344 noticed Resident #36 had not received his meal and provided him a plate of food according to his diet order. Interview on 05/18/22 at 12:45 P.M. with DP #344 revealed she was not aware Resident #36 had not received a meal until she had placed the foil covered meals on tables. She was unable to provide an explanation other than sometimes Resident #36 ate in his room. A tray would be sent to the resident's unit, prior to plates being served in the dining room and returned to the dining room if he was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 366124 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Blossom 12496 Princeton Rd Huntsburg, OH 44046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 eating in the dining room. Level of Harm - Minimal harm or potential for actual harm Interview on 05/18/22 at 2:13 P.M. with Certified Dietary Manager (CDM) #257 revealed the hall carts were prepared first, as residents came into the dining room. The residents seated closest to the serving area were served first then serving progressed towards the back of the dining room. She verified Resident #36 should have been served prior to the foil covered plates being set out for residents who had not yet arrived in the dining room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366124 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Blossom 12496 Princeton Rd Huntsburg, OH 44046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and policy review the facility failed to ensure Resident #26 had fall interventions implemented according to physician orders and/ or care plan. This affected one resident (Resident #26) of four residents (Resident's #26, #36, #37 and #45) reviewed for falls. This had the potential to affect 23 residents (Resident's #4, #12, #16, #18, #19, #24, #26, #27 #29, #31, #33, #35, #36, #37, #38, #45, #47, #49, #52, #53, #55, #158 and #159) at high risk for falls. The facility census was 54. Findings include: Review of the medical record for Resident #26 revealed an admission date of 07/25/17 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, acute respiratory failure with hypoxia, diabetes, and muscle weakness. Review of the care plan dated 07/30/21 revealed Resident #26 was at risk for falls related to deconditioning, gait and balance problems, limited mobility, poor decision-making, and history of falls. Interventions included anti-roll back brakes to wheelchair, assist with transfers and ambulation as ordered, Dycem (non-slip material) between wheelchair, cushion, and resident, mat on floor next to bed, and non-skid material to grab bar in bathroom. Review of the facility form labeled Fall Risk Evaluation, dated 03/23/22, and completed by Minimum Data Set (MDS)/ Registered Nurse (RN) #304 revealed Resident #26 was at high risk for falls due to Resident #26 was disoriented, history of falls, chair bound, on medication causing high risk for falls, and had diagnoses including at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had impaired cognition. She required extensive assist of one staff with bed mobility, transfers, and toileting. She was unable to ambulate. Review of the physician order for May 2022 revealed Resident #26 had an order dated 06/22/21 to have a mat on the floor next to her bed while she was in bed. Observation on 05/17/22 at 12:10 P.M. revealed no floor mat was observed in Resident #26's room. Resident #26 was not in her room at the time. The grab bar in Resident #26's bathroom did not have non-skid material on it. Observation on 05/18/22 at 11:02 A.M. of Resident #26 revealed she was in bed with eyes closed, and there was no mat on the floor next to her bed. Resident #26's bathroom continued to be without non-skid material to the bathroom grab bar. Interview on 05/18/22 at 11:07 A.M. with State Tested Nursing Assistant (STNA) #323 revealed she was the STNA for Resident #26. STNA #323 verified Resident #26 was in her bed with no floor mat next to her bed. STNA #323 revealed she had never seen Resident #26 with a floor mat and revealed she was not aware this was one of Resident #26's fall interventions. Interview on 05/18/22 at 11:30 A.M. with Licensed Practical Nurse (LPN) #332 revealed she was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366124 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Blossom 12496 Princeton Rd Huntsburg, OH 44046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse for Resident #26 and verified she had assisted Resident #26 to her bed. She verified she had not placed a mat by the side of her bed as she revealed she was not aware this was one of Resident #26's fall interventions and had never seen her with a mat by her bed. LPN #332 verified Resident #26 had a physician order to have a mat to the side of her bed as well as it was a care plan intervention. Interview and observation on 05/18/22 at 4:41 P.M. with the Director of Nursing (DON) verified Resident #26 was care planned to have non-skid material on her grab bar in her bathroom. Observation on 05/18/22 at 4:41 P.M. with the DON verified Resident #26 did not have non-skid material on her grab bar in her bathroom. The DON revealed Resident #26 usually used the bathroom by the nursing station on her unit. Upon observation of the bathroom by the nursing station with the DON also revealed the grab bar did not have non-skid material on the bar. Interview on 05/18/22 at 4:43 P.M. with STNA #340 verified she had never seen non-skid material on Resident #26's bathroom grab bar or on the grab bar in the bathroom by the nursing station. STNA #340 also revealed she had not seen Resident #26 have a mat by her bed and was not aware these were Resident #26's fall interventions per her plan of care and/ or physician order. Review of undated facility policy labeled Fall/ Incident Report Policy revealed the purpose of the policy was to investigate, intervene, prevent, and review falls. The policy revealed the facility would implement an intervention to prevent further incidents. The policy revealed any interventions initiated prior, the falls committee reviewed for effectiveness and either maintained or updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366124 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Blossom 12496 Princeton Rd Huntsburg, OH 44046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to maintain the indwelling urinary catheter bag in a manner to prevent urinary tract infection. This affected one (Resident #37) of one resident reviewed for an indwelling urinary catheter. The facility census was 54. Findings include: Review of the medical record for Resident #37 revealed an admission date of 02/25/10 with diagnoses including dementia without behavioral disturbances, hypertensive heart disease, and obstructive and reflux uropathy. Review of the physician's orders for Resident #37 dated 12/16/21 revealed to change the catheter and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had minimal cognitive impairment. Resident #37 required extensive one-staff physical assistance for bed mobility, dressing, and personal hygiene; supervision set-up help only for eating; and extensive two-staff assistance for toilet use. Resident #37 had an indwelling catheter for urine and was occasionally incontinent of bowel. Review of the care plan for Resident #37 dated 04/18/22 revealed she had an indwelling urinary catheter related to obstructive uropathy. Interventions included to position the drainage bag below bladder level and do not let the bag touch the floor and to use special care during transfers and turning to maintain correct bag level and avoid pulling on the tubing. Observation on 05/16/22 at 4:10 P.M. of Resident #37 ambulating herself in her wheelchair down the hallway by the dining room with her urinary catheter drainage bag underneath her chair dragging on the ground. The bag was placed in a blue dignity bag. Observation on 05/17/22 at 10:25 A.M. revealed Resident #37 in her room sleeping in her wheelchair with her urinary catheter drainage bag under chair on the ground. Observation on 05/17/22 at 10:54 A.M. of Resident #37 revealed her ambulating herself in her wheelchair from the activities room with Therapy #371. Her urinary catheter drainage bag was underneath her chair dragging on the ground. Interview on 05/17/22 at 10:54 A.M. with Therapy #371 confirmed Resident #37's urinary catheter drainage bag was dragging on the ground, and she then readjusted her urinary catheter bag to hang off the ground. Interview on 05/19/22 at 7:35 A.M. with State Tested Nursing Assistant (STNA) #306 confirmed Resident #37's urinary catheter drainage bag was often touching the ground while she was in her wheelchair due to the wheelchair being so low to the ground. Review of the facility policy titled urinary catheter care, dated 11/14/16, revealed no statement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366124 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Blossom 12496 Princeton Rd Huntsburg, OH 44046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 regarding catheter drainage bags being kept off the floor. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled indwelling catheter drainage bag dignity bags, undated, revealed no statement regarding catheter drainage bags being kept off the floor. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366124 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Blossom 12496 Princeton Rd Huntsburg, OH 44046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and review of the Ohio Department of Health, Department of Agriculture 2019 food code revealed the facility failed to serve food to residents in a sanitary manner to prevent infection. This had the potential to affect 52 residents who receive food from the kitchen. The facility identified two (Resident's #9 and #159) who did not receive food by mouth. The facility census was 54. Findings include: Observation on 05/16/22 at 12:08 P.M. revealed Dietary #325 plating food with no gloves on. Her nails appeared painted. She then stopped serving food and reached on top of her head grabbed her safety goggles and placed them back on her face. No hand hygiene was performed. Dietary #325 then began immediately began plating food again. Interview on 05/16/22 at 12:12 P.M. with Dietary #325 confirmed she was not wearing gloves. She also confirmed her nails were painted. Dietary #325 also confirmed she did touch the top of her head to grab her safety googles and put them on her face and did not wash her hands before serving food again. Interview on 05/16/22 at 12:15 P.M. with Dietary Manager #354 revealed she has instructed her staff not to wear gloves when serving food, just to handle the utensils. Review of Ohio Department of Health, Department of Agriculture 2019 food code - chapter 3717-1-02 reference guide for management and personnel, undated, revealed the facility dietary staff must maintain fingernails (nail polish/artificial nails permitted with intact gloves). The report also stated food employees must properly wash hands after coughing, sneezing, eating, drinking, tissue use, or touching body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366124 If continuation sheet Page 7 of 7

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.

FAQ · About this visit

Common questions about this visit

What happened during the May 19, 2022 survey of OHMAN FAMILY LIVING AT BLOSSOM?

This was a inspection survey of OHMAN FAMILY LIVING AT BLOSSOM on May 19, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at OHMAN FAMILY LIVING AT BLOSSOM on May 19, 2022?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·May 19, 2022