Inspection·March 25, 2024

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 record review, interview, and policy review, the facility failed to ensure care planned fall prevention interventions were in place to prevent falls. This affected one resident (Resident #8) of three residents reviewed for accidents. The facility census was 92. Findings include: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including spondylosis without myelopathy or radiculopathy, dementia, difficulty walking, history of falls, and cerebral infarction. The resident was discharged on 03/16/24. Review of the plan of care, dated 09/19/23, revealed Resident #8 was at risk for falls with interventions including toileting offer every two hours, staff to check footwear when delivering tray prior to meal, apply proper non-skid footwear if found to have none on prior meal, educate on the use of the call light for assistance, and call light to be kept within reach. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/24, revealed the resident had moderately impaired cognition with poor decision making. The resident required physical assistance for activities of daily living (ADLs). The resident's mobility device was a wheelchair. The assessment indicated there was one fall without injury and one fall with injury since admission or the prior assessment. Review of the fall risk assessment, dated 02/03/24, revealed Resident #8 was at a high risk for falls. Review of the Fall Investigation, dated 02/03/24, revealed the fall occurred on 02/03/24 at 4:01 A.M. The resident was last observed sleeping. The alarm sounded and the nurse entered the bathroom and observed the resident with half of his buttocks on the toilet seat and upper body was propped against a bin that was in the room. The resident was assessed and found to have an abrasion on his back with no additional injuries. The resident was not wearing non-skid footwear, which staff applied following the fall. Further review revealed a subsequent fall on 02/15/24. Review of the Fall Investigation, dated 02/15/24, revealed the fall occurred at 3:20 P.M. Staff responded to the sounding alarm and found the resident in the bathroom kneeling in front of the sink and was not wearing shoes or proper footwear. The resident did not sustain an injury. (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 2 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 03/25/2024 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)