Inspection·September 6, 2023

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident funds account review, record review, and interview, the facility failed to ensure conveyance of resident funds within 30 days of discharge or death. This affected three (Residents #93, #94, and #95) of three residents reviewed for personal funds. The census was 92. Residents Affected - Few Findings include: 1. Review of Resident #94's closed medical record revealed an admission date of [DATE] with diagnoses including cerebral infarction, depression, epilepsy and type two diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was usually able to understand others. Resident #94 was assessed as moderately cognitively impaired. Resident #94 discharged to another facility on [DATE]. Review of Resident #94's personal funds consent dated [DATE] revealed Resident #94 authorized the facility to manage his personal money while he was a resident. Upon discharge, the account would be closed and the funds would be returned to Resident #94. The facility was to furnish a final statement no later than 30 days after discharge. If upon discharge, the resident had unpaid charges, the resident authorized the facility to use his personal needs account funds to pay those charges prior to refusing any excess funds to the resident. Review of Resident #94's quarterly trust fund statements for the first and second quarters of 2023 revealed deposits from Social Security on a monthly basis with interest deposited. No withdrawals from the account were documented. Review of the resident funds balance reports as of [DATE] revealed Resident #94 continued to have funds in the amount of $9659.82 at the facility. During an interview with Business Office Manager (BOM) #100 on [DATE] between 1:45 P.M. and 2:02 P.M., she reported the facility started receiving Resident #94's Social Security funds in [DATE]. Resident #94 discharged to another facility [DATE]. The facility sent a check to Resident #94 in the amount of $750 on [DATE] which accounted for a $50 allowance per month since the facility started receiving Resident #94's funds. BOM #100 stated the facility had never been informed of a patient liability amount for Resident #94. BOM #100 indicated a representative from the Department of Jobs and Family Services was notified Resident #94 was in the facility at the end of 2022 (no actual date available). Because the facility had never been informed if Resident #94 would have patient liability the facility had chosen to hold the remainder of the funds until they received a determination. BOM #100 stated she had phoned a representative from the Department of Jobs and Family Services again on [DATE]. On [DATE] at 2:34 P.M., BOM #100 stated she received a return call from Department of Job and Family Services and was informed there would be no patient liability retro charged so she could release the balance of Resident #94's funds. 2. Review of Resident #93's census information revealed notations that Resident #93 had a hospital leave on [DATE]. Another notation revealed Resident #93 expired at the hospital under hospice care on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 2 of 3 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 09/06/2023 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 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #93's revealed a check dated [DATE] to the Treasurer of the State of Ohio in the amount of $4541.08, the remainder of the balance in Resident #93's account based on the second quarter resident trust fund statement. During an interview with BOM #100 on [DATE] between 1:45 P.M. and 2:02 P.M., BOM #100 verified she had not conveyed the balance of Resident #93's funds within 30 days of her death. 3. Review of Resident #95's census information revealed Resident #95 had a hospital leave on [DATE]. A notation revealed the hospital notified the facility Resident #95 was transferred from the hospital to a hospice house on [DATE] and would not be returning to the facility. Review of Resident #95's indicated a withdraw of $63.22 to close out the account leaving a balance of $0.00. During an interview with BOM #100 on [DATE] between 1:45 P.M. and 2:02 P.M., a request was made for the check conveying Resident #95's funds. BOM #100 reported the money had not been dispersed yet and she had to send the funds to state recovery. The funds were not listed on the balance report since [DATE]. This deficiency represents non-compliance investigated under Master Complaint Number OH00145438. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 3 of 3