Health inspection·February 15, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medial record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on genitourinary system, conversion disorder, hemiplegia and hemiparesis following cerebral infarction, type II diabetes, unspecified anxiety disorder, and other disorders affecting eyelid function. Review of the most recent MDS assessment dated [DATE] revealed Resident #81 had moderately impaired cognition, had self-directed behaviors, did not wander, and did not reject care. Resident #81 was a two-person assist, required total assistance with transfers, dressing, and locomotion, and required extensive assistance with bed mobility, toileting, and eating. Review of the care plan dated 01/02/23 revealed Resident #81 was at risk for alteration in nutrition/hydration related to multiple diagnoses, chronic disease, need for altered diet, need for enteral nutrition to meet dietary needs, and increased metabolic requirements. Interventions included tube feeding as ordered, Juven 1.5 at 60 ml continuous with 175 ml water flushes every three hours, cater to food preferences within dietary parameters, observe/report signs of malnutrition/dehydration, observe/report intolerance to tube feed, labs as ordered, monthly weights, report significant weight changes, and provide diet as ordered. Review of the medical record revealed Resident #81 had physician orders dated 09/20/22 for Glucerna 1.5 every shift for supplement continuously at 60 ml per hour. Observation on 02/12/23 at 8:31 P.M. revealed Resident #81 lay in bed with eyes closed making sonorous sounds. Tube feed Diabetisource was attached and running at 60 cc per hour with 175 cc water flushed every three hours. Observation 02/13/23 at 10:13 A.M. revealed Resident #81 had bag of Diabetisource tube feeding dated 02/13/23 running at 60 ml per hour with 175 ml waster flushed every three hours. Observation on 02/14/23 at 12:23 P.M. revealed Resident #81 had Diabetisource AC bag hanging and running at 60 ml per hour with 175 ml water flushed every three hours dated 02/14/23 at 12:00 A.M. During an interview on 02/14/23 12:32 P.M. with Licensed Practical Nurse (LPN) #13 stated it used to say on the dashboard in electronic medical record that the Diabetisource was comparable to the Glucerna. LPN #13 verified Resident #81 had orders for Glucerna tube feeding and had Diabetisource tube feeding hanging and running in her room. Page 1 of 5 365443 365443 02/15/2023 The Laurels of Milford 934 State Route 28 Milford, OH 45150

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/14/23 at 12:34 P.M. Registered Nurse (RN) #7 stated the facility had supply issues and could not always get the Glucerna in. RN #7 stated nurses were supposed to notify the dietitian, and a new order when switching from the Glucerna to the Diabetisource, let the doctor know, and change the order in the electronic medical record. Review of the facility policy titled Enteral Feeding Ready to Hang, effective 01/17/22, revealed the procedure included to verify the physician's order and to administer enteral feeding as ordered. Based on record review, observations, staff interviews, and review of facility policies, the facility failed to ensure tube feedings were administered as ordered. This affected two (#49 and #81) out of the three residents reviewed for tube feedings during the annual survey. The facility census was 110. Findings include: 1. Record review for Resident #49 revealed this resident was admitted to the facility on [DATE] and had diagnoses including neuronal ceroid lipofuscinosis, dysphagia, generalized idiopathic epilepsy, constipation, dyspnea, increased secretion of gastrin, dementia, acute respiratory failure with hypoxia, and gastrostomy status. Review of the annual Minimum Data Set (MDS) assessment, dated 12/06/22, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility and transfers, to be dependent upon one staff member for eating, and to require extensive assistance from two staff members for toileting. This resident was assessed to have a feeding tube and to have not had significant weight loss. Review of the care plan, most recently revised on 04/14/22, revealed Resident #49 was unable to tolerate nutritionally adequate food and/or fluids by mouth and required use of a feeding tube. Interventions included administer tube feeding as ordered, notify physician if tube becomes dislodged, and provide care to tube site as ordered. Review of the care plan, most recently revised on 01/12/23, revealed Resident #49 had a nutritional risk. Interventions included tube feeding regimen as ordered. Review of the physicians order, dated 11/30/22 and discontinued on 02/12/23, revealed an order to administer Osmolite 1.2 Cal at 60 milliliters (ml) per hour. Review of the active physicians order, dated 02/13/23, revealed an order to administer Isosource 1.5 Cal at 50 ml per hour. Review of the Medication Administration Record (MAR) for 02/2023 revealed on 02/12/23 Osmolite 1.2 Cal had been documented as being administered at 60 ml per hour on night and day shift. On day shift on 2/14/23 Isosource 1.5 was documented as being administered at 50 ml per hour as ordered. Review of the nurses progress note, dated 02/12/23 and timed 9:10 P.M. revealed Osmolite unavailable. Nurse practitioner contacted with new order for Isosource 1.5. Family aware. Observation on 02/12/23 at 7:10 P.M. revealed Resident #49 was receiving the tube feeding solution Osmolite 1.2 Cal at a rate of 38 ml per hour. Interview with Licensed Practical Nurse (LPN) #33 at 365443 Page 2 of 5 365443 02/15/2023 The Laurels of Milford 934 State Route 28 Milford, OH 45150

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the time of the observation verified the tube feeding solution was infusing at a rate of 38 ml per hour despite being ordered to be infused at 60 ml per hour. Observation on 02/14/23 at 12:41 P.M. revealed Resident #49 was receiving the tube feeding solution Isosource 1.5 Cal at a rate of 60 ml per hour. Interview with Registered Nurse (RN) #7 at the time of the observation verified the tube feeding solution was infusing at a rate of 60 ml per hour despite being ordered to be infused at 50 ml per hour. 365443 Page 3 of 5 365443 02/15/2023 The Laurels of Milford 934 State Route 28 Milford, OH 45150

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 record review, observations, staff interview, and policy review, the facility failed to implement their policy to ensure oxygen tubing was changed weekly. This affected two residents (#33 and #81) of three residents reviewed for respiratory care. The facility census was 110. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #33 revealed an admission date of 08/06/21. Diagnoses included multiple myeloma, chronic diastolic heart failure, unspecified heart failure, Stage III chronic kidney disease, pressure ulcer of the sacral region, unspecified dementia, generalized anxiety disorder, pseudobulbar effect, unspecified depression, and unspecified schizophrenia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had severely impaired cognition, had verbal and self-directed behaviors, did not reject care, and did not wander. Resident #33 was a two-person physical assist, required extensive assistance for transfers, dressing, toileting, and personal hygiene, and eating, and total assistance for bed mobility and locomotion. Review of the care plan dated 01/23/23 revealed Resident #33 had potential for difficulty breathing and risk for complications related to shortness of breath. Interventions included meds as ordered, oxygen as ordered, encourage cough/deep breathing, observe/report difficulty breathing, and observe/report signs of respiratory distress/anxiety/respiratory infection. Review of the medical record revealed Resident # 33 had physician orders dated 01/21/2023 for Oxygen per nasal cannula to maintain saturation levels greater than 90% Observation on 02/13/23 at 10:02 A.M. revealed Resident #33 wore oxygen per nasal cannula at two liters per minute dated 02/05/23. Observation on 02/14/23 at 12:25 P.M. revealed Resident #33 wore oxygen per nasal cannula at two liters per minute dated 02/05/23. 2. Review of the medial record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on genitourinary system, conversion disorder, hemiplegia and hemiparesis following cerebral infarction, type II diabetes, unspecified anxiety disorder, and other disorders affecting eyelid function. Review of the most recent MDS assessment dated [DATE] revealed Resident #81 had moderately impaired cognition, had self-directed behaviors, did not wander, and did not reject care. Resident # 81 was a two-person assist, required total assistance with transfers, dressing, and locomotion, and required extensive assistance with bed mobility, toileting, and eating. Review of care plan dated 01/13/23 revealed Resident #81 was at risk for cardiac complications related to multiple cardiovascular diseases. Interventions included meds as ordered, monitor/report signs of cardiac distress, and give oxygen as ordered. Observation on 02/13/23 at 10:07 A.M. revealed Resident #81 wore oxygen per nasal cannula at two 365443 Page 4 of 5 365443 02/15/2023 The Laurels of Milford 934 State Route 28 Milford, OH 45150

F 0695 liters per minute dated 02/05/23. Level of Harm - Minimal harm or potential for actual harm Observation on 02/14/23 at 12:26 P.M. revealed Resident #81 wore oxygen per nasal cannula at two liters per minute dated 02/05/23. Residents Affected - Few During an interview on 02/14/23 at 12:27 P.M. Licensed Practical Nurse (LPN) #13 stated oxygen tubing is changed weekly on all units on Sunday night shift. LPN #13 verified oxygen tubing for Residents #33 and #81 were outdated and should have been changed on 02/12/23. Interview with the Administrator on 02/14/23 at 5:30 P.M. revealed there were no physicians orders in place to change oxygen tubing, however, staff were aware oxygen tubing was to be changed every Sunday. Review of policy titled Use of Oxygen dated 08/17/2021 revealed the oxygen cannula should be changed weekly and dated. 365443 Page 5 of 5