Inspection·December 11, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, medical record review and staff interview the facility failed to ensure indwelling urinary catheter care was documented and assessed appropriately. This affected one (Resident #78) of two residents reviewed for indwelling urinary catheter use. The facility identified eight residents (#2, #3, #6, #7, #56, #67, #78 and #100) currently utilizing an indwelling urinary catheter. The facility census was 91.Observation of Resident #78 on 12/08/25 at 10:08 A.M. identified the current use of an indwelling urinary catheter. Review of Resident #78's medical record revealed an admission date of 11/30/25 with admission diagnoses that included urinary retention, osteonecrosis of the right knee and convulsions. Further review of the medical record revealed upon admission a physician's order for the use of an indwelling urinary catheter and catheter care to be provided every shift. Further review of the medical record found no evidence of any assessment which identified the current use and indication for the indwelling urinary catheter. Review of the treatment administration record (TAR) revealed no evidence of indwelling catheter care documented as provided as ordered by the physician until 12/07/25.Interview with the Director of Nursing on 12/09/25 at 3:30 P.M. verified no evidence of indwelling catheter care documented as provided from admission to 12/07/25 and no assessment identifying the use and indication for the use of an indwelling urinary catheter was completed. Event ID: Facility ID: 366169 If continuation sheet Page 2 of 4 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 12/11/2025 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, interview, record review, facility policy review, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to ensure staff used appropriate infection control practices using required proper hand hygiene for Resident # 6 with use of gloves during incontinence care for Residents #6. This affected one ( Resident #6) and had the potential to affect all 91 residents residing in the facility.Findings include:Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease, unspecified, Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding, Urinary tract infection, site not specified, Retention of urine, unspecified, Generalized anxiety disorder, Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, Parkinson's disease with dyskinesia, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Personal history of urinary calculi, and Long term (current) use of anticoagulants.Review of the Minimum Data Set (MDS 3.0) assessment dated [DATE] revealed Resident #6 has intact cognition, she has an indwelling catheter and is sometimes incontinent of bowel and dependent for continence care.Observation and chart review on 12/09/25 for Resident # 6 indicated order for catheter care every shift and incontinence care as needed.Observation on 12/10/25 at 9:45 A.M. revealed Resident # 6 for incontinence care with Certified nursing assistant (CNA)# 168 and CNA # 218. CNA #168 and CNA # 218 sanitized hands and donned proper personal protective equipment (PPE) for enhanced barrier precautions (EBP). CNA # 168 emptied catheter bag into graduate cylinder and measured output. Barrier placed under cylinder. CNA# 168 cleaned end of catheter tube with alcohol before securing it. At 9:46 A.M. CNA# 218 emptied urine output measured. (250mL) Urinal rinsed. At 9:49 A.M. CNA # 168 and CNA # 218 changed gloves, did not sanitize or wash hands. Donned new gloves. Resident # 6 dirty brief removed. At 9:51 A.M. CNA # 168 used wet washcloth with soap, cleaned Resident # 6 from front to back. Catheter tube wiped with same washcloth. At 9:53 A.M. Resident # 6 wiped front to back with clean washcloth. At 9:54 A.M. CNA # 168 used dry towel to pat dry front to back. Resident # 6 had bowel movement. Resident # 6 was rolled over and CNA# 218 cleaned Resident # 6 cleaned with wet washcloth front to back, washed with clean washcloth front to back. At 9:55 A.M. CNA # 218 patted Resident # 6 dry. At 9:56 A.M. dirty brief removed from Resident # 6 and clean brief applied to Resident # 6, CNA# 168 and CNA # 218 did not change dirty gloves or wash/sanitize hands prior to handling clean brief. CNA # 218 pulled Resident # 6 blankets over Resident with dirty gloves. At 9:57 A.M. CNA # 168 and CNA # 218 repositioned Resident # 6 with dirty gloves. At 9:58 A.M. all dirty material placed in garbage bag and pulled out of Resident # 6 room. Interviews on 12/10/25 at 9:59 A.M. with CNA# 168 and CNA # 218 confirmed they did not change gloves and did not use proper hand hygiene during entire process after the initial hand washing for Resident # 6.Interviews on 12/11/25 at 9:20 A.M. with Director of Nursing (DON) # 190 confirmed the facility had a policy in place confirming soiled gloves should be changed and hand hygiene should be performed before placing a clean brief on Resident # 6. Staff will be educated on proper hand hygiene and infection control practices. Review of facility policy confirmed Care Standards, dated 04/2018 revealed catheter usage will include avoidance of infection, use infection control aspects of incontinence care. Review of Hand Hygiene in Healthcare Settings, Healthcare Providers, Glove Use, last reviewed 01/08/21, from the Centers for Disease Control and Prevention, located at https://www.cdc.gov/handhygiene/providers/index.html revealed gloves are not a substitute for hand hygiene. Change gloves Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 3 of 4 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 12/11/2025 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 and perform hand hygiene during patient care if gloves become visibly soiled with blood or body fluids following a task and moving from work on a soiled body site to a clean body site on the same patient. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366169 If continuation sheet Page 4 of 4