Inspection·December 9, 2022

F 0583 Keep residents' personal and medical records private and confidential. 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 resident's confidential information was not left visible on unattended computer screens. This affected three residents (Resident #51, #67 #74) of six observed for medication administration. Residents Affected - Few Findings included: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included diabetes, major depressive disorder, COVID-19, dysphagia, port-traumatic stress disorder, anxiety disorder, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, gout, and osteoarthritis. Observation on 12/05/22 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #815 assembled her equipment and went into the room of Resident #51 to perform blood glucose testing. LPN #815 left Resident #51's medical information on the computer screen. LPN #815 verified at 11:19 A.M. she had not closed out the resident information on her computer screen when she went into the resident's room. Review of the facility policy titled, Privacy, Dignity, and Confidentiality, dated 01/22, revealed residents had the right to privacy including the right to personal privacy and confidentiality of his or her personal and clinical records. The policy indicated residents had the right to personal privacy which included accommodations, medial treatment, written and telephone communications, personal care visits, and meetings of family and resident groups. The policy indicated resident's clinical records would be kept confidential and private. 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included obsessive compulsive disorder, COVID-19, anxiety disorder, hoarding disorder, adult failure to thrive, and hypothyroidism. Observation on 12/06/22 at 8:15 A.M. revealed Registered Nurse (RN) #871 went into Resident #67's room to give her medication. RN #871 left Resident #67's private medical information up on the computer screen while she was inside the resident room. At 8:25 A.M., RN #871 verified she left Resident #67's private information up on the computer screen while she was in the room. Review of the facility policy titled, Privacy, Dignity, and Confidentiality, dated 01/22, revealed residents had the right to privacy including the right to personal privacy and confidentiality of his or her personal and clinical records. The policy indicated residents had the right to personal privacy which included accommodations, medial treatment, written and telephone communications, personal care visits, and meetings of family and resident groups. The policy indicated resident's clinical records would be kept confidential and private. 3. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, COVID-19, dementia, delirium, diabetes, major depressive disorder, delusional disorder, anxiety disorder, social phobia, congestive heart failure, metabolic encephalopathy, and auditory hallucinations. Observation on 12/06/22 at 8:19 A.M. revealed RN #871 went into the room of Resident #74 to give her medication. RN #871 left Resident 74's information up on the computer screen while she was inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 2 of 16 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 12/09/2022 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)

F 0583 the room. At 8:25 A.M., RN #871 verified this concern. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Privacy, Dignity, and Confidentiality, dated 01/22, revealed residents had the right to privacy including the right to personal privacy and confidentiality of his or her personal and clinical records. The policy indicated residents had the right to personal privacy which included accommodations, medial treatment, written and telephone communications, personal care visits, and meetings of family and resident groups. The policy indicated resident's clinical records would be kept confidential and private. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 3 of 16 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 12/09/2022 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 interviews the facility failed to ensure appropriate nail care was provided to Resident #32, who was dependent on staff for her personal care. This affected one of three residents reviewed for activities of daily living (ADLs). Residents Affected - Few Findings included: Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included dementia, chronic kidney disease, weakness, macular degeneration, diabetes, major depressive disorder, anemia, congestive heart failure, hypothyroidism, osteoarthritis, and COVID-19. Review of the plan of care dated 11/20/18 revealed Resident #32 was limited in her ability to perform all ADLs due to chronic kidney disease, acute kidney failure, and diabetes with neuropathy. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #32 had moderately impaired cognition and required extensive assistance of one staff for personal hygiene. Review of the progress notes dated 05/22/22 through 11/30/22 revealed no evidence Resident #32 refused to have her finger nails cleaned and trimmed. Review of the facility shower sheets dated 09/28/22, 09/29/22, 10/05/22, 10/06/22, 10/19/22, 10/27/22, 10/29/22, 11/16/22, 11/29/22, 11/30/22, and 12/01/22 revealed no documentation that Resident #32 had her nails trimmed or cleaned. The shower sheets had a box to check if this care was provided and it was not checked on any of the shower forms for any of these dates. Observations on 12/04/22 at 9:28 A.M., 11:30 A.M. and 1:53 P.M. revealed Resident #32 had very long dirty finger nails. At 1:53 P.M., an interview with Resident #32 revealed her nails had not been trimmed in a while and she did not like them long. Observation on 12/05/22 at 9:15 A.M. revealed Resident #32's finger nails were still very long and dirty. On 12/05/22 at 11:22 A.M. interview with the Director of Nursing (DON) revealed nails should be trimmed and cleaned on shower days and as needed. The DON verified Resident #32's finger nails were long and dirty. At the time of this observation, Resident #32 stated she was glad they were going to trim them for her. Review of the undated facility policy titled, Nail Care, revealed the purpose of this procedure was to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Nail care including trimming and filing would be provided as needed. Nails should be kept smooth to avoid skin injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 4 of 16 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 12/09/2022 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of Resident #75 on 12/04/22 at 9:30 A.M. and at 10:25 A.M. revealed Resident #75 sitting in a reclined broda chair (an adaptive, reclining seating device) in the unit lounge area. Residents Affected - Few Review of Resident #75's medical record revealed an admission date of 10/30/22 with diagnoses that included Parkinson's disease and Alzheimer's disease. The Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] indicated Resident #75 had severely impaired cognition and no restraints were used and he required staff assistance for all acitivities of daily living. Review of Resident #75's nursing progress notes and occupational therapy notes revealed the use of a the broda chair had been used admission. Review of the physician's orders revealed no evidence of a physician's order in place for the use of a broda chair until 12/05/22. Review of Resident #75's assessments found no evidence of an assessment for the use of the broda chair to determine if it was a restraint or a safety intervention until 12/06/22. Interview with the Director of Nursing on 12/07/22 at 10:22 A.M. verified there was no physician's order for the use of the broda chair since admission until 12/05/22 and there was assessment of this potential physical restraint/assistive device for comfort completed until 12/06/22. Based on observation, record review and interview the facility failed to ensure Resident #23 received an appropriate substitution for his physician ordered nutritional supplement and the facility failed to timely assess Resdient #75 for the use of a Broda chair. This affected one of five residents reviewed for nutrition and one of one resident reviewed for a possible restraint. The facility census was 85. Finding included: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included squamous cell carcinoma of skin, acute respiratory failure, severe protein calorie malnutrition, diabetes, atrial fibrillation, chronic lymphatic leukemia, major depressive disorder, chronic obstructive pulmonary disease, hypertension, atherosclerotic heart disease, nutritional deficiency, and anxiety disorder. Review of the significant change Minimum Data Set assessment dated [DATE] revealed Resident #23 had moderately impaired cognition and had a prognosis of less than six months to live. Review of the progress note dated 11/20/22 at 2:41 P.M. revealed Resident #23's appetite was very poor and he hardly ate any food but he did drink his Med Pass nutritional supplement and asked for these cold drinks frequently. Review of the current December 2022 physician orders revealed Resident #23 still had a physician order for 120 milliliters (mls) of Med Pass (nutritional supplement) three times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 5 of 16 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 12/09/2022 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the December 2022 medication administration record revealed Resident #23 did not receive the 120 mls of Med Pass on 12/03/22 and 12/04/22 because it was not available. Observation on 12/06/22 at 7:51 A.M. revealed Licensed Practical Nurse (LPN) #849 poured a five-ounce plastic cup three fourths full with Jevity 1.5 and administered it to Resident #23 to drink. LPN #849 indicated she was using it in replace of the Med Pass supplement which the resident was ordered. LPN #849 said they were not able to order Med Pass supplement due to a manufacture supply issue. The facility dietitian provided a list of supplements acceptable to use due to supply chain issues. This list revealed acceptable substitutions for the Med Pass supplement would be facility health shakes, sugar-free healthshakes, Mighty shakes or sugar-free Mighty shakes. Jevity 1.5 was not on the list of acceptable substitutions for Med Pass. Review of the manufacture information for Jevity 1.5 Cal revealed it was a calorically dense, fiber-fortified therapeutic nutrition that provided complete, balanced nutrition for long-term or short-term tube feeding and was only to be used with residents with altered taste perception. Comparison of nutritional values revealed 120 mls of Med Pass three times a day provided 720 calories and 30 grams of protein and Jevity 1.5, 120 mls, three times daily only provided 535 calories and 23 grams of protein. On 12/06/22 at 12:24 P.M. interview with Dietitian #889 revealed she was not aware nursing staff was substituting Jevity 1.5 for Med Pass for Resident #23. Dietitian #889 stated it was not a one to one equivalent replacement for Med Pass. She stated they should have been using one of the other equivalent health shakes/in-house supplements from the list she had provided to the facility for a one to one substitution when there were supply chain issues. On 12/06/22 at 3:30 P.M., interview with Resident #23 revealed the supplement the nursing staff had been giving him to drink tasted horrible. He stated he did not know what it was called but it was not the same one he had been receiving before. On 12/07/22 at 8:54 A.M., interview with the Director of Nursing verified there were no additional physician's orders obtained to change nutritional supplements for Resident #23, when the ordered Med Pass supplement was not available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 6 of 16 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 12/09/2022 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)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure glasses were provided for Resident #17 in a timely manner following a optometry appointment. This affected one of one resident reviewed for vision. The facility census was 85. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 07/26/22 with diagnoses that included congestive heart failure, pressure ulcer to the sacrum and diabetes mellitus. Review of the 360 Optometry consult revealed Resident #17 was evaluated in the facility on 07/24/22. At that time the optometrist ordered new glasses pending insurance/payer approval. The Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 11/03/22 revealed Resident #17 was alert and oriented with intact cognition. This assessment indicated Resident #17 had impaired vision and but did not use any corrective lenses. Further review of the medical record found no evidence of any approval or additional notes related to approval or lack thereof for Resident #17's glasses. Interview with Resident #17 on 12/04/22 at 10:54 A.M. revealed she had saw the optometrist several months ago and had not received her glasses which were ordered at that time. On 12/07/22 at 10:18 A.M. interview with the Director of Nursing verified Resident #17 has not received her glasses and the facility has not followed up to determine the status of glasses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 7 of 16 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 12/09/2022 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement an individualized and effective pressure ulcer prevention program to prevent the in house development and/or worsening of pressure ulcers to Resident #11's bilateral heels. Residents Affected - Few Actual harm occurred on 09/22/22 when Resident #11, who was severely cognitively impaired, required extensive assistance from two staff for bed mobility and was at risk for developing pressure ulcers was identified to have a blister to the left heel without evidence of adequate care/interventions to promote healing. On 09/30/22 Resident #11 was assessed to have a blister measuring 5.0 centimeters (cm) in length by 6.0 cm width with no depth to her right heel with no evidence adequate care/interventions to promote heating. On 10/13/22 the wound physician noted the left heel pressure ulcer had deteriorated and was a deep tissue injury (DTI), a persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues measuring 6.7 centimeters (cm) in length by 8.0 cm width with an undetermined depth and a DTI pressure ulcer to the right heel which measured 3.7 cm by 5.0 cm and had an undetermined depth. The pressure ulcers continued to deteriorate to unstageable ulcers. The facility failed to timely implement pressure ulcer prevention measures (including pressure relief/reduction measures and a dietitian consult) to prevent and treat the ulcers. This affected one resident (#11) of five residents reviewed for pressure ulcers. Finding included: Review of the medical record revealed Resident#11 was admitted to the facility on [DATE] with diagnoses including gout, hypertension, osteoarthritis, and polyneuropathy. Review of the admission Skin assessment dated [DATE] revealed Resident #11 had no skin injuries or open areas to either of her heels. Review of the Braden scale for risk for development of pressure ulcers, dated 09/14/22 revealed Resident #11 was at risk for developing pressure ulcers. Review of the physician's orders, dated 09/14/22 revealed Resident #11 had orders for a skin assessment to be completed weekly. Review of the plan of care, dated 09/14/22 revealed Resident #11 had pressure ulcer prevention interventions to float her heels off the bed surface while in bed and to have a pressure relieving mattress. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severely impaired cognition and required extensive assistance of two staff for bed mobility and transfers. She was admitted to the facility with one Stage II pressure ulcer on her coccyx. Review of the physician orders dated 09/20/22 revealed Resident #11 had orders for ProHeal (a nutritional supplement) everyday for healing and Arginaid (a protein supplement) twice daily for pressure ulcer healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 8 of 16 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 12/09/2022 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)

F 0686 Review of a skin/body assessment, dated 09/22/22 revealed Resident #11 had a new fluid-filled blister to her left inner heel measuring 6.0 centimeters (cm) in length by 5.0 cm width with no depth noted. Level of Harm - Actual harm Residents Affected - Few Review of the progress note, dated 09/22/22 at 5:26 P.M. revealed during a shower it was noticed Resident #11 had a fluid filled blister to her left inner heel. A new physician order was received to pad and protect the blister area with a thick abdominal (ABD) dressing and wrap with Kerlix gauze wrap daily and as needed. Review of a Braden scale assessment, dated 09/22/22 revealed Resident#11 was at risk for developing pressure ulcers. There was no documentation found to indicate staff were floating Resident #11's heels from the time of admission until 09/22/22 when this pressure ulcer was identified. Review of the plan of care, dated 09/27/22 revealed Resident #11 had a new intervention for a low air loss mattress. There was no physician order written for the low air loss mattress at that time. Review of a skin/body assessment, dated 09/30/22 revealed Resident #11 had new pressure area, a blister measuring 5.0 cm in length by 6.0 cm width with no depth to her right heel. A physician order was obtained this date for nursing staff to pad and protect the right heel blister with an ABD dressing and wrap with Kerlix gauze daily and as needed. Review of a wound physician note, dated 10/06/22 revealed the physician ordered a low air loss mattress, an air boot and a prealbumin test for the resident. Review of the written physician's order dated 10/06/22 revealed Resident #11 was ordered application of skin prep to her heel and cover with a ABD dressings and wrap with Kerlix gauze daily and as needed. Review of a progress note, dated 10/06/22 at 2:15 P.M. (written as a late entry dated 11/29/22 at 12:20 P.M.) revealed Resident #11 was seen by the wound physician who gave an order for an air boot. The note indicated the nurse showed the wound physician the facility's heel protectors and the physician stated those were acceptable to use in place of the air boots. Review of the physician' orders revealed there were no orders written on 10/06/22 for heel protectors or for any substitute for the air boot. Review of laboratory testing results, dated 10/07/22 revealed Resident #11 had a prealbumin level of 17 milligrams/deciliter (mg/dl) (normal range 17-34 mg/dl). Review of a wound physician's note, dated 10/13/22 revealed Resident #11's left heel was a deep tissue injury (DTI), a persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues was measuring 6.7 cm in length by 8.0 cm width with an undetermined depth. The note indicated the pressure ulcer was deteriorating. Resident #11's right heel DTI measured 3.7 cm in length by 5.0 cm width with an undetermined depth and was noted to be improving. Review of the physician's orders, dated 10/13/22 revealed Resident #11 had a new order to cleanse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 9 of 16 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 12/09/2022 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)

F 0686 the left and right heel DTI's with normal saline (NS), pat dry, apply oil emulsion, cover with an ABD and wrap with Kerlix gauze daily and as needed. Level of Harm - Actual harm Residents Affected - Few Review of a wound physician's progress note, dated 10/20/22 revealed Resident #11's left heel DTI measured 3.2 cm in length by 3.5 cm width with an undetermined depth and was improving. The right heel DTI was measured at 4.9 cm length by 5.0 cm depth with an undetermined depth and was assessed to have deterioration. There was a new physician order to change boots from the sponge boots to prevalon pressure-relieving boots and to consult the dietitian concerning her prealbumin level. Review of the physician orders revealed no orders were written by the wound physician on 10/20/22 for prevalon boots or a dietitian consult as he indicated in his progress note. Review of the wound physician progress note, dated 10/27/22 revealed the left heel DTI was assessed to have deteriorated to an unstageable (obscured full-thickness skin and tissue loss) due to necrosis/eschar (black/dark brown dead, devitalized tissue). The wound measured 3.0 cm in length by 3.5 cm width with an undetermined depth and was covered with 70 percent eschar and 30 percent granulation (healthy tissue). Resident #11's right heel was documented as measuring 4.7 cm length by 4.7 cm width with an undetermined depth and still discolored. Review of a wound physician's note, dated 11/10/22 revealed Resident #11's left heel unstageable DTI measured 2.1 cm in length 2.8 cm width with an undetermined depth and was healing. The eschar had unroofed and the area was violet, boggy, with intact skin. The right heel DTI was assessed to have declined and was now unstageable with 100 percent necrosis and measured 2.1 cm in length by 1.5 cm width with an undetermined depth. The wound physician indicated Betadine would be ordered for treatment. Review of the plan of care, dated 11/18/22 revealed a new intervention for pressure relieving ankle foot orthotic (Prafo) boots to both of Resident #11's heels were ordered. However, there was no physician order found for Prafo boots. Review of a physician's order, dated 11/20/22 revealed Resident #11 had a new order for nursing staff to apply Betadine to both of her heels, cover with an ABD and wrap with Kerlix gauze daily and as needed. Review of the wound physician's note dated 11/25/22 revealed Resident #11's left heel unstageable DTI measured 1.6 cm in length by 2.2 cm width with an undetermined depth and had eschar. The note documented the pressure ulcer was stable. Resident #11's right heel unstageable DTI measured 2.0 cm length by 1.5 cm width with an undetermined depth and was covered 100 percent by eschar and was declining. Review of the wound physician's note, dated 12/01/22 revealed Resident #11's left unstageable heel DTI measured 1.6 cm length by 2.2 cm width with an undetermined depth and had eschar. The note indicated the pressure ulcer was stable. Resident #11's right heel was an unstageable DTI and measured 2.1 cm length by 1.3 cm width with an undetermined depth with eschar covering 100 percent of the pressure ulcer wound. On 12/04/22 at 10:00 A.M. Resident #11 was observed in bed with her feet/heels wrapped in Kerlix gauze wrap as ordered, however there was no Prafo boot to either heel (the most current intervention implemented). In addition, the resident's heels were not floated off the bed surface as a pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 10 of 16 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 12/09/2022 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)

F 0686 reduction intervention. Level of Harm - Actual harm On 12/04/22 at 11:33 A.M., Resident #11's heels were observed propped up on a pillow and not floated off the bed to relieve pressure. Residents Affected - Few Review of the physician's orders, dated 12/05/22 revealed Resident #11 had new orders for heel protectors while in bed and a low air loss mattress. On 12/06/22 at 11:20 A.M. observation of Resident #11's pressure ulcers with Licensed Practical Nurse (LPN) #859 and LPN #886 revealed the resident's left heel had two unstageable black areas, were mushy and the resident stated it hurt. The resident's right heel was observed with black eschar covering the whole heel area. The heel was mushy and the edges were red and inflamed. LPN #859 verified the observation and condition of the resident's heels. On 12/06/22 at 12:55 P.M. interview with LPN #859 revealed Resident #11 was admitted to the facility with a skin alteration to her coccyx but no skin alterations/pressure ulcers to her heels. LPN #859 verified Resident #11 was assessed to be at risk for developing pressure ulcers. LPN #859 indicated Resident #11 had a pressure reliving mattress to the bed on admission which was changed to a low air loss mattress according to the plan of care dated 09/27/22. However, the LPN then indicated the air mattress was not implemented until 10/07/22 and no physician order was written for it until 12/05/22. LPN #859 verified there was never a physician order written for the prevalon boots and no evidence Resident #11 ever received them. LPN #859 verified the plan of care dated 11/18/22 revealed a new intervention for Prafo boots for Resident #11's heels, but no physician order was written. LPN #859 verified she wrote the physician's orders for the heel protectors and loss air loss air mattress on 12/05/22. On 12/07/22 at 9:35 A.M. interview with Dietitian #889 revealed she was never consulted the resident's low pre-albumin (ordered 10/20/22). She indicated if she had been consulted, she may have adjusted supplements to add more protein to aid in healing of Resident #11's pressure ulcers. On 12/07/22 at 10:10 A.M. interview with the Director of Nursing revealed she did not know why the dietitian consult was not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 11 of 16 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 12/09/2022 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure oxygen tubing/nasal cannulas and aerosol equipment (tubing/mouthpieces) for respiratory treatments were changed and dated weekly and properly stored to prevent infection/contamination when not in use for Residents #8, #36, #37 and #49. This affected four of 13 residents reviewed for oxygen therapy/breathing treatments. Residents Affected - Some Findings included: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included chronic pulmonary (lung) disease, chronic respiratory failure, hypertension, atrial fibrillation, diabetes, anxiety, obstructive sleep apnea, atherosclerotic heart disease, affective mood disorder, and insomnia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was alert,oriented with intact cognition, required extensive assistance of two staff members for bed mobility, transfers, toilet use and one staff member for dressing and personal hygiene. Review of the December 2022 physician's orders revealed Resident #36 had an order for oxygen per nasal cannula at three liters continuous for comfort and for oxygen saturations below 90% and directed that oxygen tubing was to be changed and dated weekly. Resident #36 was also ordered albuterol sulfate solution for nebulization (breathing or aerosol treatments) as needed for shortness of breath. Review of the November and December 2022 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed no documentation of Resident #36 oxygen tubing or breathing treatment tubing and mouthpiece being changed weekly. Observation on 12/04/22 at 9:37 A.M. revealed the oxygen nasal cannula (nose piece) of her portable oxygen tank for Resident #36 was laying directly on her wheelchair seat and the mouth piece for her her respiratory treatments was laying directly on her bedside table and neither were in protective bag or cover. Resident #36 was observed wearing the nasal cannula connected to the oxygen tubing from her regular oxygen concentrator. The nasal cannula attached to the oxygen tubing she was wearing, the nasal cannula lying in her wheelchair and the mouthpiece for her breathing treatment were not dated to indicate when they were last changed. On 12/04/22 at 9:37 A.M. an interview with Resident #36 revealed she has not had her oxygen tubing, nasal cannulas or aerosol mouthpiece equipment changed in weeks. On 12/04/22 at 10:17 A.M. an interview with Licensed Practical Nurse (LPN) #853 verified Resident #36's her oxygen tubing, nasal cannulas, and aerosol mouthpiece should be dated as to when they were last changed and the nasal cannula for her portable oxygen tank and the aerosol mouthpiece should be stored in a protective bag when not in use to prevent contamination. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included pneumonia, congestive heart failure, atrial fibrillation, chest pain, hypertension, diabetes, anxiety disorder, hypoxemia, dyspnea, and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #8 was alert, oriented and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 12 of 16 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 12/09/2022 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)

F 0695 had intact cognition and required oxygen therapy. Level of Harm - Minimal harm or potential for actual harm Review of the December 2022 physician orders revealed Resident #8 had a current order for oxygen per nasal cannula at three liters continuously for her comfort and for oxygen saturation less than 90 percent. Staff were to change her oxygen tubing weekly. Residents Affected - Some Review of the November and December 2022 MARs and TARs revealed no documentation of Resident #8's oxygen tubing being changed. Observation on 12/04/22 at 10:00 A.M. revealed the oxygen tubing and nasal cannula Resident #8 was wearing and her portable oxygen nasal cannula tubing were not dated to indicate when they had last been changed. Resident #8's portable oxygen nasal cannula was not in use and was observed hanging on the back on her wheelchair. It was not in any type of protective bag. On 12/04/22 at 10:16 A.M., LPN #853 verified Resident #8's oxygen tubing and cannulas were not properly dated to determine when they were last changed and her portable oxygen cannula was not in a protective bag when not in use to prevent contamination. 3. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, mental status changed, chronic kidney disease, COVID-19, heart failure, dementia, dependence on supplemental oxygen, sand sleep apnea, chronic obstructive pulmonary disease, and anxiety disorder. Review of the annual MDS assessment dated [DATE] revealed Resident #37 had moderately impaired cognition and received oxygen therapy. Review of the December 2022 physician orders revealed Resident #37 had current orders for oxygen per nasal cannula at two to four liters for resident comfort or for oxygen saturations below 90 present and for ipratropium/albuterol breathing treatments every six hours while awake. Resident #37 also had orders for the oxygen tubing and breathing treatment tubing/mouthpiece to be changed weekly. Review of the November and December 2022 MARs and TARs revealed no documentation of Resident #37's oxygen tubing or aerosol tubing/mouthpiece being changed. Observation on 12/04/22 at 9:45 A.M. revealed the aerosol mouthpiece, the portable oxygen nasal cannula/tubing and the nasal cannula/tubing on the oxygen concentrator which Resident #37 was wearing were not dated to indicated when they were last changed. The portable nasal cannula was hanging uncovered on the back of Resident #37's wheelchair and her breathing treatment mouthpiece was lying directly on her bedside stand and was not in any type of protective bag. On 12/04/22 at 10:15 A.M., LPN #853 verified Resident #37's oxygen tubing, nasal cannulas and aerosol mouthpiece/tubing should be dated as to when it was lasted changed and her portable oxygen nasal cannula and aerosol mouthpiece should be in a protective bag when not in use. 4. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, cerebral infarction, heart failure, lymphedema, major depressive disorder, hemiplegia, and diabetes. Review of the annual MDS assessment dated [DATE] revealed Resident #49 had moderately impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 13 of 16 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 12/09/2022 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)

F 0695 cognition, and received oxygen therapy. Level of Harm - Minimal harm or potential for actual harm Review of the December 2022 physician orders revealed Resident #49 had current orders for oxygen via nasal cannula continuously, albuterol sulfate breathing treatments four times daily, and staff directed to change the oxygen tubing and breathing treatment tubing/mouthpiece every week. Residents Affected - Some Review of the November and December 2022 MARs and TARs record revealed no documentation of Resident #49's oxygen tubing or breathing treatment tubing/mouthpiece being changed weekly. Observation on 12/04/22 at 10:05 A.M. revealed the oxygen tubing, nasal cannula and breathing treatment mouthpiece for Resident #49 were not dated to indicate when they were last changed. The breathing treatment mouthpiece was lying directly on Resident #49's bedside table and was not covered with any type of protective bag. On 12/04/22 at 10:17 A.M., LPN #853 verified Resident #49's is oxygen tubing, nasal cannula and breathing treatment mouthpiece were not properly dated with the date they were lasted changed. LPN #853 verified Resident #49's breathing treatment mouthpiece should be in a protective bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 14 of 16 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 12/09/2022 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #186's meal consistency was provided per the physician order. This affected one (Resident #186) of seven residents reviewed for food and nutrition. Findings include: Review of Resident #186's medical record revealed she was admitted on [DATE] with diagnoses including cardiomegaly, diabetes and hemiplegia. Review of Resident #186's physician orders revealed an order dated 11/29/22 for a pureed diet with sugar substitute and thin liquids. Observation on 12/05/22 at 12:10 P.M. revealed Resident #186 was sitting in the dining room on the 100/200 units and she was served a pureed plate of stuffed cabbage with mashed potatoes. On the left side of the plate was a square piece of white cake with icing which was not pureed as indicated in the physician orders. Interview on 12/05/22 at 12:10 P.M. with Dietary Supervisor #885 confirmed Resident #186 was served white cake with icing which had a regular consistency, which was an error and it should have been a pureed consistency based on the physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 15 of 16 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 12/09/2022 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)

F 0880 Provide and implement an infection prevention and control program. 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 perform hand washing prior to administering insulin to Resident #51 to prevent the potential spread of infection. This affected one resident (Resident #51) of two observed for injections. Residents Affected - Few Findings include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included diabetes, post-traumatic stress disorder, anxiety disorder, and chronic obstructive pulmonary disease. Review of the December 2022 physician orders revealed Resident #51 had a order for Humalog, an injectable insulin medication for diabetes, 10 units three times daily. Observation of glucometer testing on 12/05/22 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #815 assembled her equipment and went into Resident #51's room. LPN #815 completed the blood sugar test with the glucometer and placed it on Resident #51's bedside table. LPN #815 went back to the medication cart in the hallway cleaned the glucometer with a Sani-wipe, a disinfectant wipe, and placed it in a disposable plastic cup and removed her gloves. LPN #815 did not wash or sanitize her hands and proceeded to retrieve Resident #51's Humalog insulin Flex-pen from the top drawer of the medication cart. She went into Resident #51's room without washing her hands, put on gloves and administered the insulin to Resident #51. LPN #815 went back out the the medication cart and placed the insulin Flex-pen back into the top drawer of the medication cart and then sanitized her hands. Interview with LPN #815 on 12/05/22 at 11:19 A.M. verified she had not washed or sanitized her hands after obtaining the glucometer reading, touching the medication cart and prior to administering Resident #51's insulin. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 04/20, revealed practicing hand hygiene was a simple effective way to prevent infections by preventing the spread of germs. Staff were directed to wash their hands after removing gloves and before and after nursing treatment or procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 16 of 16