Health inspection·December 5, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview, the facility failed to ensure a residents wall, ceiling, and fan were clean. This affected one (Resident #77) of one reviewed for respiratory care. The facility census was 125. Findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with a re-entry date of 03/13/18. Diagnoses included traumatic brain injury, acute and chronic respiratory failure. Review of quarterly minimum data set (MDS) dated [DATE] revealed Resident #77 was rarely/never understood, had severely impaired cognitive skills for daily decision making, and was totally dependent upon staff for all activities of daily living (ADLs). Review of physician order dated 12/02/19 revealed Resident #77 had a tracheostomy, a surgical placed tube in the front of the neck for breathing, and oxygen was ordered as needed to maintain oxygen saturation levels above 90 percent. Observation on 12/03/19 at 9:15 A.M. revealed Resident #77 was asleep in bed with oxygen being administered via tracheostomy. A pedestal fan was located directly beside Resident #77's bed, next to oxygen equipment, and was blowing air directly towards resident's face. The fan guard was covered in dust with one inch dust strings blowing straight out from the front of the fan. [NAME] splatters were observed on the ceiling above the resident and on the upper wall at the head of the bed. During interview on 12/05/19 at 10:01 A.M., with Licensed Practical Nurse (LPN) #395 following tracheostomy care to Resident #77, acknowledged the fan was covered in dust and was blowing directly on Resident #77. LPN #395 reported the fan was utilized by the resident continuously and maintenance cleaned the fan monthly. LPN #395 also verified the brown splatters on the wall and ceiling, was unsure what the brown substance was, and reported housekeeping would be notified to see if the brown splatters were able to be removed. During interview on 12/05/19 at 10:18 A.M. Registered Nurse (RN) #500 reported the brown splatters were most likely secretions expelled from Resident #77's tracheostomy upon coughing. Page 1 of 5 365443 365443 12/05/2019 The Laurels of Milford 934 State Route 28 Milford, OH 45150

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interview, review of the controlled substance log and policy review, the facility failed to ensure the nurse observed residents during medication administration and failed to ensure controlled substances were accounted for each shift. This affected one Resident (#276) and had the potential to affect any resident prescribed a controlled substance. This affected one of one emergency box controlled substances located in one of two medication rooms reviewed during the survey and had the potential to affect any resident prescribed controlled substances. The facility census was 125. Findings include: 1. Observation on 12/04/19 at 2:22 P.M. of the A/B medication room revealed a emergency medication box of controlled substances secured with a numbered breakaway lock. Review of shift change emergency box controlled substance log revealed on 11/15/19 at 7:00 A.M. only the off going nurse signed the log and documented the controlled box lock number at 16117600. The oncoming signature box remained blank. On 11/16/19, the same nurse signed oncoming and then off going without the time noted or another nurse witness signature, as these spaces remained blank. The box lock number remained 16117600. There weren't any nurse signatures for 11/17/19. On 11/18/19, one nurse signed as oncoming at 7:00 A.M. without another nurse witness signature and documented the box lock number as 16117620. On 12/04/19 at 7:00 A.M., one nurse signed as oncoming without another nurse signing as a witness or off going. Interview on 12/05/19 at 10:58 A.M. with the Director of Nursing reported the facility had one emergency box for controlled substances. A numbered, break away lock was utilized to secure the box. Every time the keys to the medication room were exchanged, both nurses were to verify the box had not been opened by ensuring the same numbered breakaway lock was securely in place. The controlled substance log was then signed by both nurses which indicated the emergency box of controlled substances was secured. If the box was accessed, two nurses reconciled the contents of the box, placed a new numbered breakaway lock on the box, signed and noted the new lock number on the controlled substance log to maintain an accurate reconciled inventory. The DON confirmed the emergency box controlled substance log was not signed every shift, as required, by both the oncoming and off going nurses. Review of the facility policy titled Inventory Control of Controlled Substances, dated 12/01/07, revealed facility should ensure that the incoming and outgoing nurses count all Schedule two controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily. 2. During observation on 12/04/19 at 10:19 A.M., a medication cup with pills was on the resident's over bed table. The resident was not in the room at the time of the observation. Interview at that time with Licensed Practical Nurse (LPN) #376 revealed she had left his morning medication in his room on the table, unattended. The resident did not have an order to self-administer medications. Review of the facility policy titled, Medication Administration, dated July 2009, revealed the 365443 Page 2 of 5 365443 12/05/2019 The Laurels of Milford 934 State Route 28 Milford, OH 45150

F 0755 staff is to remain with the guest while administering oral medication to verify the medication consumption. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365443 Page 3 of 5 365443 12/05/2019 The Laurels of Milford 934 State Route 28 Milford, OH 45150

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview, review of drug manufacturer instructions and policy review, the facility failed to ensure the medication error rate was less than five percent (%). A total of 29 medications were observed administered with two errors for a error rate of 6.9%. This affected one Resident (#113) of six observed for medication administration. The facility census was 125. Residents Affected - Few Findings include: Observation on 12/05/19 at 8:02 A.M. revealed Licensed Practical Nurse (LPN) #380 administered medications by mouth to Resident #113 including cholestyramine four grams mixed with four ounces of water, one multivitamin with minerals, finasteride five milligrams (mg), Sertraline 75 mg, Hydroxyzine 50 mg, tamsulosin 0.4 mg, and Lorazepam one mg. The pharmacy label on the package of tamsulosin instructed to take the medication one half hour after the same meal each day. Medical record review for Resident #113 revealed a physician order for cholestyramine four gram packet, give one packet orally three times a day for diarrhea. Administer at least one hour prior to routine medications or four hours after. Interview on 12/05/19 at 8:48 A.M. with Resident #113 reported he had not received or eaten a meal yet but breakfast should be delivered soon. Interview on 12/05/19 at 8:51 A.M. with LPN #380 verified the physician order for Resident #113's cholestyramine instructed the medication should have been administered one hour prior to other medications and acknowledged this medication was administered with morning routine medications in error. LPN #380 confirmed the label on the package of tamsulosin instructed to administer the medication one half hour after the same meal each day and reported Resident #113 had not yet received a meal. Review of drug manufacturer instructions for tamsulosin revealed the medication should be administered approximately one half hour following the same meal each day. Review of the facility policy titled Medication Administration, revised July 2009, revealed all medications and treatments shall be initiated, administered, and/or discontinued in accordance with written physician orders. Medications with specific established timeframes from the manufacturer will be administered within the manufacturer's guidelines. 365443 Page 4 of 5 365443 12/05/2019 The Laurels of Milford 934 State Route 28 Milford, OH 45150

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and record review, the facility failed to prepare pureed food according to the recipe and failed to serve palatable food. This had the potential to affect all facility residents except Resident #77 and Resident #85, who consumed nothing by mouth. The facility census was 125. Residents Affected - Some Findings include: Observation on 12/04/19 at 11:00 A.M. of preparation of pureed mixed vegetables revealed staff did not follow the approved recipe. Dietary [NAME] (DC) #355 placed mixed vegetables, with the two cups of water in which they were steamed, in the food processor. When DC #355 determined an agent was needed for thickening, she stated they were out of thickener, so she substituted three one-pound boxes of corn starch. Observation of lunch tray line service on 12/04/19 at 11:40 P.M. revealed pureed mixed vegetables on the steam table with visible clumps of corn starch and a very thick consistency that could not be stirred with a whisk. Dietary Manager #360 instructed staff serving the food to add hot water to the mixture to attempt to get the vegetables to the correct texture to serve to the residents requiring a pureed diet. During an interview with Dietary Aide #700 on 12/04/19 at 12:00 P.M., she stated the pureed vegetables were more of a pudding texture, had lumps and had a texture similar to glue. She reported to Dietary Manager #360 the texture was not correct for serving, she was not able to get it to the right texture by adding water and questioned if she was required to serve this item. Dietary Manager #360 responded the entire tray line would be held while another vegetable was prepared for residents who required a pureed texture. On 12/04/19 at 12:50 P.M. a test tray was sampled. The temperatures for the food were sweet potatoes at 154.2 degrees Fahrenheit, cabbage at 126.5 degrees F, ham at 105.4 degrees F, milk at 43.5 degrees F and juice at 45.9 degrees F. The Dietary Manager reported hot food should be above 131 degrees F and under 41 degrees F for cold food. She stated the temperatures for this food service were not adequate to provide to residents. Food items were tested with the Dietary Manager and the food was not palatable. Dietary Manager #360 stated the cabbage was not seasoned or crisp and the sweet potatoes had a bad taste. During an interview with Dietician #701 on 12/04/19 at 2:46 P.M., she stated there was a recipe for the preparation for pureed mixed vegetable that should have been followed. The texture should be smooth with no chunks and not gummy and should be a consistency similar to mashed potatoes. On 12/04/19 at 3:35 P.M. Dietician #701 reported there was no policy in place to substitute corn starch for thickener and corn starch was not recommended for use as a thickener for pureed food. 365443 Page 5 of 5