Inspection·August 22, 2019

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident with a mental illness that admitted to hospice services. This affected one (Resident #48) of one resident reviewed for significant change PASARR. The facility census was 89. Findings include: Record review revealed Resident #48 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia without behavioral disturbance, chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, disorder of lipoprotein metabolism, heart failure, hypertension, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, heart failure, hypothyroidism, obstructive sleep apnea, anemia, psychotic disorder with delusions due to known physiological condition and dementia in other diseases classified elsewhere with behavioral disturbance. Review of Resident #48's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required supervision with bed mobility, transfers, eating and toileting. Resident #48 was also independent with personal hygiene and dressing on the 08/16/19 MDS. Further review of Resident #48's MDS assessments revealed the resident had a significant change MDS completed on 05/17/19. Review of Resident #48's progress notes revealed the resident was discharged to the psychiatric hospital on [DATE] due to an escalation of behavior related to her grieving a relative. Resident #48 readmitted to the facility from the psychiatric hospital on [DATE]. Review of Resident #48's PASARR dated 03/16/18 revealed the PASARR was obtained upon Resident #48's initial admission to the facility on [DATE]. Resident #48's chart did not contain a significant change PASARR or notification to the state mental health agency upon Resident #48's psychiatric hospitalization on 10/25/19 or Resident #48's significant improvement in activities of daily living on 05/17/19. Interview with Registered Nurse (RN) #340 on 08/21/19 at 2:29 P.M. verified Resident #48 had a significant change MDS assessment completed on 05/17/19 due to a significant improvement in activities of daily living. Interview the Director of Nursing (DON) on 08/22/19 at 9:26 A.M. verified notification to the state mental health authority of the significant change PASARR was not completed upon Resident #48's psychiatric hospitalization on 10/25/19 or Resident #48's significant improvement in activities of daily living on 05/17/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 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 365628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE S.E.M. Haven Health Care Center 225 Cleveland Avenue Milford, OH 45150 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medical record review, observation, interview, review of manufacturer guidelines, review of International Pharmacopeia 2017 and review of facility policy the facility failed to discard medications after the recommend date and failed to label medications when opened. This directly affected one Resident (#238) whose insulin pen was not dated. The facility identified seven residents who received insulin with pens. This also directly affected three Residents (#22, #63, #68) who had eye medications that were dated beyond 30 days. The facility identified 61 residents who received eye drops. The census was 89 residents. Findings include: 1. Review of Resident #22's medical record revealed an admit date of 02/16/10 and diagnoses of dementia, depressive disorder, anxiety, and osteoarthritis. Review of August 2109 physician orders revealed an order for Akwa tears/Liquifilm Tears one drop to each eye every four hours as needed for dryness. 2. Review of Resident #63's medical record revealed an admit date of 10/06/18 and diagnoses of dementia, chronic respiratory failure, depressive disorder, diabetes, and osteoarthritis. Review of August 2019 physician orders revealed an order for Artificial Tears one drop to each eye three times a day. 3. Review of Resident #68's medical record revealed an admit date of 04/24/19 with diagnoses of heart failure, chronic kidney disease, anemia, and hypertension. Review of August 2019 physician orders revealed an order for Refresh Optive Gel one drop to each eye three times a day. Artificial Tears one drop to each eye three times a day. 4. Review of Resident #238's medical record revealed an admit date of 07/26/19 with diagnoses of coronary graft, deep vein thrombosis, diabetes, and malignant neoplasm of esophagus. Review of August 2019 physician orders revealed an order for Basaglar insulin pen 15 units at bedtime Observation on 08/21/19 from 11:00 A.M. to 11:35 A.M. of resident room medication storage areas revealed Resident # 22 had a bottle of artificial tears with a handwritten date of 04/17/19, Resident #63 had a bottle of artificial tears with a handwritten date of 01/15/19, Resident #68 had a bottle of Refresh Optive Gel with a handwritten open date of 07/18/19, and Resident #238 had an Basaglar insulin pen without any date written on the affixed label, there was a blank open date line. Interview during the observations with the facility Director of Nursing (DON) verified the above findings. She also stated she expected all insulin pens to be dated when removed from the refrigerator. Interview on 08/21/19 at 11:19 A.M. with Licensed Practical Nurse (LPN) #422 reported the Basaglar insulin pen for Resident #238 was undated, currently in use, and should be discarded 28 days after usage began. Review of Lilly Pharmaceutical online instructions for Basaglar usage indicated - once you begin injecting with a Pen throw it away after 28 days. Review of International Pharmacopeia, Seventh Edition, dated 2017 revealed ophthalmic drop (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 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 365628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE S.E.M. Haven Health Care Center 225 Cleveland Avenue Milford, OH 45150 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 0761 preparations may be used for up to four weeks after the container is initially opened. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Medication Storage, undated, revealed medications are stored under necessary conditions to ensure stability. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 If continuation sheet Page 4 of 4