Health inspection·January 9, 2020

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure a timely pressure ulcer re-assessment was completed for Resident #51, following the resident's readmission to the facility and failed to implement physician orders for pressure ulcer prevention and treatment for Resident #76. This affected two residents (#51 and #76) of four residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. Residents Affected - Few Findings include: 1. Review of Resident #51's medical record revealed an admission date of 02/14/18 with diagnoses including end stage renal disease, acquired absence of right leg above knee amputation, periprosthetic fracture around internal prosthetic left hip joint, respiratory failure, anemia, weakness, hyperlipidemia, dependence on renal dialysis, hypothyroidism, obstructive sleep apnea, Type 2 diabetes mellitus, chronic systolic (congestive) heart failure, macular degeneration, hypertension, morbid (severe) obesity, major depressive disorder, generalized anxiety disorder, hypotension of hemodialysis, blepharitis right eye, neuromuscular dysfunction of bladder, carcinoma of endometrium, chronic kidney disease, stage 4 (severe) and gastritis. Review of the 12/19/19 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making, required extensive assist of two staff for bed mobility, was totally dependent of two staff for transfers, did not walk, required extensive assist of one staff for locomotion on the unit and total assist of one staff for locomotion off the unit. The assessment revealed the resident required extensive assist of one staff for dressing, was independent for eating, totally dependent of two staff for toileting, extensive assist of one staff for personal hygiene, required physical help in part of bathing of one staff. The assessment revealed the resident's balance was not steady as the resident was only able to stabilize moving from seated to standing, moving on and off the toilet and surface to surface transfer, the resident had lower extremity impairment on one side, utilized a manual wheelchair and had one Stage III (full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) are often present. At this stage, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface) pressure ulcer with a pressure reducing device for chair and bed. Review of a 12/19/19 Weekly Pressure Ulcer Progress Report revealed the resident had a house acquired left ishium pressure ulcer discovered 07/30/19 that currently was a Stage III pressure ulcer measuring 2.7 centimeters (cm) in length by 1.4 cm width with 0.8 cm depth. There was a moderate amount of serosanguinous drainage with small pink granulation, large eschar and slough adherent to the wound bed and small epithelialization. Periwound has excoriation/erythema, but no crepitus, induration Page 1 of 9 366169 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

F 0686 or edema. Level of Harm - Minimal harm or potential for actual harm Review of a 12/20/19 Braden Scale for Prediction of Pressure Sore Risk revealed the resident was slightly limited for sensory perception, had very moist skin, was chair fast, had very limited mobility, excellent nutrition, problems with friction and shearing and a moderate risk for skin breakdown. Residents Affected - Few The resident was hospitalized [DATE]. The hospital wound note, dated 12/27/19 included the left ishium pressure ulcer was 2.0 cm by 2.5 cm by 0.5 cm Stage III pressure ulcer with scant serosanguinous drainage and a red wound bed. The resident returned to the facility 01/03/20. The readmission skin assessment included multiple bruises covering bilateral upper extremities and antecubital regions bilaterally, petechial areas observed over anterior and posterior aspect of right stump, a scabbed area to dorsal left foot and a pre existing wound to gluteal folds present. There was no evidence of a comprehensive pressure ulcer assessment upon readmission. Review of the physician's orders included 01/03/20 a broda chair to provide postural support and comfort secondary to poor trunk control post right above the knee amputation and an order to cleanse left gluteus with soap and water, apply medihoney to wound bed and then calcium alginate, cover with border dressing, and change every other day and as needed. The first comprehensive assessment of the pressure ulcer, following re-admission, was completed 01/06/20. The pressure ulcer was 2.3 cm in length by 2.7 cm width with 0.5 cm depth with a moderate amount of serosanguinous drainage. Interview on 01/09/20 at 12:20 P.M. with the Director of Nursing (DON) verified there was not a comprehensive assessment/measurements of the existing Stage III pressure ulcer at the time of the resident's 01/03/20 readmission. The DON revealed all pressure ulcers were to be comprehensively assessed upon readmission. 2. Review of Resident #76's medical record revealed an admission date of 08/22/19 with diagnoses including osteoarthritis, right wrist, pain right wrist, hand and left hand, weakness, adult neglect or abandonment, asthma, hepatitis A, and adhesive capulitis of right shoulder. Review of the physician's orders included 08/23/18 elevate heels from bed surface while in bed and 09/01/19 low air loss mattress to bed to promote skin integrity. Review of the plan of care dated 08/23/18 revealed the resident was at risk for skin breakdown related to impaired mobility. Interventions included 06/17/19 use of a low air loss mattress to bed to promote skin integrity and float heels while in bed as resident will allow. Review of the 11/17/19 quarterly MDS 3.0 assessment revealed the resident was independent for daily decision making, required extensive assist of two staff for bed mobility, was totally dependent on two staff for transfers, required extensive assist of one staff for dressing, was independent for eating, required extensive assist of two staff for toileting, extensive assist of one staff for personal hygiene and had a pressure reducing device for bed. A 12/20/19 Braden Scale Prediction of Pressure Sore Risk included the resident had slightly limited sensory perception, was constantly moist, bedfast, completely immobile, had probably inadequate 366169 Page 2 of 9 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

F 0686 nutrition, and had a problem with friction and shear making the resident a very high risk for pressure ulcers. Level of Harm - Minimal harm or potential for actual harm Observation 01/06/20 at 11:04 A.M. revealed the resident was in bed with an Airflow Aircon 2 air mattress. The motor was on the footboard in the off position. The resident's heels were not elevated or floating. Observation 01/06/20 at 6:34 P.M. revealed the Airflow Aircon 2 motor remained in the off position and the hose connecting the motor to the mattress was detached. The resident's heels were not elevated or floating at the time of the observation. Residents Affected - Few Interview on 01/06/20 at 6:32 P.M. with Licensed Practical Nurse #100 verified the resident was in bed and the air mattress was not turned on and was disconnected from the mattress. Further verification occurred the resident's heels were not elevated or floating. Observation on 01/07/20 at 8:25 A.M. revealed the resident was in bed. The air mattress was in the on position but her heels were not elevated or floating. Interview with the resident at the time of the observation revealed she could not walk and didn't like to get out of bed. The resident verified her heels were not elevated and were directly on the bed. Interview on 01/07/20 at 8:44 A.M. with State Tested Nursing Assistant (STNA) #142 revealed the resident only gets out of bed for showers. STNA #142 revealed she had not noticed the air mattress was not turned on the day prior and verified she had not elevated the heels. Interview on 01/07/20 at 2:14 P.M. with the resident's son revealed the resident's heels were not elevated when he visits daily between 2-2:30 P.M. The son pulled up the covers and verified her heels were not elevated and there was not a pillow for elevation the area. 366169 Page 3 of 9 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, record review and staff interview the facility failed to ensure a contracture splinting device was in place as ordered by the physician for Resident #13. This affected one resident (#13) of two residents reviewed for limited range of motion. The facility identified eight residents with limited joint range of motion. Findings include: Review of Resident #13's medical record revealed an admission date of 06/09/2016 with admission diagnoses that included cerebrovascular accident with hemiplegia and hemiparesis. Review of the medical record revealed on 02/15/2019 Resident #13 had a physician order for the use of a left cock up splint to be worn from 9:00 A.M. to 5:00 P.M. to prevent further loss of range of motion. Review of the medical record found no evidence Resident #13 was receiving any physical or occupational therapy services at this time. Review of Resident #13's plan of care revealed a care plan in place for a limitation of range of motion and an intervention including the use of a left wrist cock up splint to be worn per restorative. Review of Resident #13's treatment administration record (TAR) revealed instructions for staff to apply a left wrist cock up splint at 9:00 A.M. and remove at 5:00 P.M. every day. Further review of the TAR revealed staff members signed the TAR to indicate the splint was in place every day as ordered. Observation of Resident #13 on 01/06/2020 at 10:41 A.M. revealed a left hand and wrist contracture with no evidence of any splint device in place. Continued observations on 01/06/2020 at 2:24 P.M., 01/07/2020 at 8:54 A.M., 01/07/2020 at 9:26 A.M., 01/07/2020 at 11:32 A.M., 01/08/2020 at 8:50 A.M. and 01/08/2020 at 10:05 A.M. also revealed no splint in place to Resident #13's left hand/wrist contracture. Observations revealed a splint was noted lying on top of Resident #13's dresser and not in use. Interview with State Tested Nursing Assistants (STNA) #15 and #20 on 01/08/2020 at 10:50 A.M. revealed Resident #13 was currently receiving therapy services and no longer receiving restorative services including splint placement at this time. Interview with Registered Nurse (RN) #10 on 01/08/2020 at 11:10 A.M. revealed Resident #13 was not on any type of therapy caseload and was currently receiving restorative nursing services for the use of wrist splint due to a left hand/wrist contracture. RN #10 further stated staff members should be applying Resident #13's splint every morning. RN #10 verified Resident #13 does not have a splint in place at this time. 366169 Page 4 of 9 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

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, record review and interview the facility failed to ensure physician's orders were followed for Resident #191 related to an indwelling urinary catheter and failed to ensure the resident had an appropriate indication for use of the indwelling urinary catheter. This affected one resident (#191) of two residents reviewed for indwelling urinary catheter use. The facility identified six residents with use of any indwelling urinary catheter. Findings include: Review of Resident #191's medical record revealed an admission date of 12/20/2019 with diagnoses that included left femur fracture with surgical repair and infection to the surgical area. Further review of the medical record revealed a nurse to nurse communication form from the transferring facility on 12/20/2019 that indicated the use of an indwelling urinary catheter and instructed the facility to remove the catheter in seven days. Review of the physician's orders revealed an order for the indwelling catheter to be removed in one week. Further review of the medical record found no evidence the indwelling urinary catheter was removed or evidence of an appropriate indication for continued use of the indwelling urinary catheter. Observation of Resident #191 on 01/06/2020 at 2:27 P.M. revealed the use of an indwelling urinary catheter. Continued observations on 01/07/2020 at 11:36 A.M. and 12:50 P.M. revealed the continued use of the indwelling urinary catheter. Interview with Resident #191 on 01/06/20202 at 2:30 P.M. revealed the use of the indwelling urinary catheter was due to an inability to walk or stand on her leg due to an infection. Interview with Registered Nurse (RN) #10 on 01/07/2020 at 3:15 P.M. verified the indwelling urinary catheter for Resident #191 was not removed seven days after admission on [DATE] as ordered and also verified the resident currently had no appropriate indication for continued use of the catheter. 366169 Page 5 of 9 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review and staff interview the facility failed to ensure menu pureed and regular portion sizes were followed during the lunch meal on 01/07/20. This had the potential to affect 94 of 94 residents who received meal trays from the facility, with the exception of Resident #141 who did not receive nutrition from the kitchen. The facility census was 95. Findings include: Review of the lunch menu/spreadsheet for the 01/07/20 lunch meal revealed the meal included mustard glazed beef, mashed potatoes, carrots or green beans, wheat bread and assorted desserts. Observation of the lunch tray line on 01/07/20 at 11:20 A.M. with [NAME] #106 and Dietary Manager #102 revealed the serving of wheat bread was not served with the lunch meal. Review of the menu spreadsheet for Week 3 Day 3 revealed the meal included one slice of wheat bread. Observation of the pureed diet revealed the pureed mustard glazed beef was served with a #8 (four ounce scoop). Review of the menu spreadsheet revealed the pureed beef was to be served with a #6 (5 1/3 ounce scoop), more than what was provided. The pureed carrots were served with a #16 (two ounce scoop). The spreadsheet listed a scoop size of a #12 (2 2/3 ounces) of carrots, more than what was provided. Interview on 01/07/20 at 11:28 A.M. with Dietary Manager #102 revealed the kitchen staff forgot to wrap the individual servings of wheat bread and it was not being served on the trays. Dietary Manager #102 verified they forgot to serve the wheat bread until it was brought to their attention the wheat bread was on the lunch menu and not being served. This affected all the residents in the facility except Resident #114 who did not receive a tray from the kitchen. DM #102 verified the pureed carrots and pureed beef were being served with a smaller scoop size than what was ordered on the Fall/winter menu Week 3 Day 3 which was signed by the Dietician. DM #102 included the pureed diets had the bread portion pureed with the beef. Interview on 01/07/20 at 3:55 P.M. with Dietician #101 revealed the scoop size of the pureed meat entree did not include adding the bread portion to the meat when pureed. Dietician #101 revealed when bread was added to the meat the serving size should go up one level to include the addition of the pureed bread which was not done. 366169 Page 6 of 9 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and staff interview the facility failed to pureed food to the correct consistency. This had the potential to affect three residents (#27, #31 and #60) who received a pureed diet. The facility census was 95. Findings include: Observation on 01/07/20 at 3:20 P.M. revealed [NAME] #104 was pureeing the supper meal. Riblet sandwiches were substituted for the ham on the Week three Day three supper menu. [NAME] #104 placed 10 and 2/3 bun halves in the cuisinart. [NAME] #104 added one half cup of water, one fourth cup barbeque sauce, one half teaspoon beef base, and two tablespoons of thickener. [NAME] #104 added 10 ounces of riblet to the mixture and blended. The mixture was placed in a tin. [NAME] #104 did not taste the mixture for consistency. When asked to check the consistency there was fibrous tissue in the puree. DM #102 tasted the puree verifying fibers were not fully broken down. [NAME] #104 returned the puree to the cuisinart and was pureed to a creamy consistency. Interview on 01/07/20 at 3:50 P.M. with DM #102 verified the riblet sandwich puree was not pureed to a smooth consistency and contained fibrous food. DM #102 verified they usually do not taste the puree for texture. [NAME] #104 revealed there were three residents, Resident #27, #31 and #60 who received pureed diets. 366169 Page 7 of 9 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

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, record review and staff interview the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect 94 of 94 residents who received meal trays from the facility, with the exception of Resident #141 who did not receive nutrition from the kitchen. The facility census was 95. Findings include: Initial tour of the kitchen on 01/06/20 at 9:45 A.M. revealed the following: The walk in refrigerator contained: - leftover peas which not dated - leftover beef a roni dated 12/30/19 - leftover gluten free pancake mix dated 12/18/19 In the walk in freezer: - chocolate ice cream was observed with the lid off - French toast with the bag opened and not sealed exposing the french toast the freezer air - beef tacos open to air - eggplant cutlets open to air - ground beef patties open to air The reach in refrigerator contained the following: There were three individual servings of cottage cheese dished out and not covered. There were six yogurt and eight jello in individual cups uncovered on a tray dated 01/04/20. There were cobwebs on the ansel system over the cooking stovetop surface. The shelf over the cooktop was greasy and dusty. The top of the convection oven was dusty and grimy. The steamer was leaking onto the floor. The seal on the handle side was allowing steam to escape the length of the door when shut. Review of maintenance invoices revealed the facility had diagnostics of the steamer completed and a draft pressure switch installed 08/19/19. On 09/20/19 a door gasket seal was installed. Invoices 366169 Page 8 of 9 366169 01/09/2020 Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460

F 0812 Level of Harm - Minimal harm or potential for actual harm for 10/01/19 and 10/03/19 revealed the steamer was checked over. They found the unit needed descaled and a vent repiped. The steamer was replumbed and a vent pipe installed per manufacturer specification. New elbows, pipe and piping parts were installed. Descale was placed in the water reservoir, let work for an hour and flushed completely. The operation was rechecked. Residents Affected - Many There was no temperatures logged for the dishwasher on 01/04/20 and 01/05/20 for the supper meal. Review of the night aide cleaning schedule revealed on Wednesday's all stainless steel shelves were to be cleaned. Review of the Storage Procedures policy revised 11/2017 revealed food should be covered, perishable dated, and stored loosely to permit circulation of air. Unwashed produce was to be stored below washed produce. Prepared perishables such as salads, puddings, milk should be stored in a refrigerator and covered until used. Leftovers were to be refrigerated immediately and used within 5-7 days with a use-by date clearly marked. All foods in the freezer were to be wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Interview during the initial tour and at 10:15 A.M. with Dietary Manager (DM) #102 verified the freezer food items were open to air, the refrigerator leftovers were undated and outdated, the shelves and ansel system had cobwebs, were dusty and grimy. Further, verified the steamer was broken leaking water on the floor and steam escaping out the side. DM #102 revealed they had tried to fix the steamer twice and it did not work Interview on 01/06/20 at 10:05 A.M. with Dietary #112 verified the food items in the reach in refrigerator were uncovered. Interview on 01/09/20 at 11:35 A.M. with DM #102 verified the steamer was better on preheat but still leaked and steam escaped on cook. DM #102 included she failed to let anyone know the steamer was still broken. 366169 Page 9 of 9