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 (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 9 Event ID: 366169 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 366169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blossom Nursing and Rehab Center 109 Blossom Lane Salem, OH 44460 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)