Inspection·December 14, 2022

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 interview, the facility failed to ensure a resident with a significant change in mental status had the pre-admission screening and resident review (PASARR) screening revised. This affected one (Resident #48) of five residents reviewed for PASARR screening. The facility census was 92. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE]. Diagnoses included for Resident #48 included dementia and Parkinson's disease. Review of PASARR screening, dated 02/07/19, revealed the resident did not have indications of a serious mental illness and did not required a level two mental health screening. Record review revealed new diagnosis of psychotic disorder with delusions on 11/10/21 and frontotemporal neurocognitive disorder on 12/08/21. Record review revealed no new PASARR was completed after the resident was newly diagnosed with a mental illness. During interview on 12/07/22 at 3:30 P.M., the Director of Nursing verified Resident #48 had new psychiatric diagnosis after the original PASRR had been completed and a revision should have been submitted to the Ohio Department of Job and Family Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 If continuation sheet Page 2 of 6 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 12/14/2022 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary for a resident. This affected one (Resident #87) of two residents reviewed for discharge. The facility census was 92. Findings include: Record review revealed Resident #87 was admitted to the facility on [DATE] and discharged on 11/08/22 to home. Review of the closed record for Resident #87 revealed no documentation of the recapitulation of the resident's stay from admission date of 10/25/20 through 11/08/22 including the resident's clinical status, and care instructions to ensure coordination of transition from the facility to home. During interview on 12/06/22 at 10:36 A.M., the Director of Nursing verified a discharge summary had not been completed by the interdisciplinary clinical team employees for Resident #87 after discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 If continuation sheet Page 3 of 6 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 12/14/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interview and policy review, the facility failed to ensure a resident was changed into night clothing. This affected one (Resident #71) of two residents reviewed for dignity. The facility census was 92. Residents Affected - Few Findings include: Review of the medical record for the Resident #71 revealed an admission date of 08/25/22. Diagnoses included cognitive communication deficit, mood disturbance, anxiety, unspecified dementia, and emphysema. Review of the plan of care dated 08/26/22 revealed the resident have an activity of daily living self-care performance deficit. Interventions includes dressing: set up assist shirt while assisting. Pants when supine in bed and footwear. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/18/22, revealed the resident had impaired cognition. The resident required extensive assistance with one person assist for dressing. During observation on 12/04/22 at 10:35 A.M., Resident #71 stated she was wearing the same clothing as the day before. She was wearing a floral shirt. Resident stated she preferred to be in her night clothes. During observation and verified by State Tested Nursing Assistant (STNA ) #133, Resident #71 had several pairs of pajamas in her dresser drawer. During interview on 12/04/22 at 10:45 A.M., STNAs #131, #188 and #250 stated they had not changed Resident #71's clothing today on day shift and night shift had not changed her clothing. Review communication sheet from night staff to day staff; revealed Resident #71 did not get dressed from night shift. During observation on 12/05/22 at 10:30 A.M., Resident #71 was sitting in her room watching television wearing an orange T-shirt. During observation on 12/05/22 at 5:20 P.M.,Resident #71 was in bed. Resident #71 was still wearing the orange T-shirt. Resident #71 stated she was in bed for the night and was waiting on staff to change her into her evening clothes. During observation on 12/06/22 at 9:12 A.M., Resident #71 was lying in bed, still dressed in the same orange T-shirt as the day prior. Resident #71 stated no one changed her into her evening clothes again. During interview at the time of the observation, STNA #252 stated she had not changed Resident #71's clothing nor was her clothing changed on night shift. Review of the facility policy titled Resident Rights, dated October 2019, revealed residents have autonomy and choice, to maximum extent possible, about how they wish to live their lives and receive care, subject to the SEM Haven Resident and Family Information booklet and that describes nursing and personal care issues and daily life at our home. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 If continuation sheet Page 4 of 6 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 12/14/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to maintain adequate infection control practices during wound care. This affected one (Resident #39) out of one resident reviewed for wound care. The facility census was 92. Residents Affected - Few Findings include: Record review revealed Resident #39 was admitted on [DATE]. His diagnoses included urinary tract infection, hypotension, rhabdomyolysis, bacterial pneumonia, syncope, visual hallucinations, chronic kidney disease, constipation, dysphasia, anemia, vascular dementia, anxiety, and hyphenate. Review of the physician orders for Resident #39 revealed an order dated 10/04/22 to apply betadine moist gauze to bilateral buttocks pressure ulcer and cover with army battle dressing (ABD) pad twice daily every 12 hours for wound care and every 1 hours as needed for wound care. During observation on 12/06/22 at 1:37 PM, Licensed Practical Nurse (LPN) #146 completed wound care. LPN #146 washed her hands, donned gloves and removed the old dressing from Resident #39's wound. She then cleaned the wound with saline and gauze. Without washing her hands, LPN #146 donned clean gloves and completed the treatment. During interview at the time of the observation, LPN#146 confirmed she failed to wash her hands after removing the soiled dressings and prior to applying the clean dressings to Resident #39. Review of the facility policy titled Dressing Change-Clean, dated May 2011, documented Procedure- 10. Put on gloves. Remove old dressings carefully, touching only edges and place in plastic bag. 11. Assess the area for signs of infection, drainage and/or signs and symptoms of healing. 13. Change gloves and wash hands. 14. Apply treatment/dressings. Review of the facility policy titled Hand Washing/Hand Hygiene, dated June 2011, documented Handwashing and use of hand sanitizer shall be regarded by this organization as the most important means of preventing the spread of infections. Appropriate thirty 15-20 second handwashing must be preformed under the following conditions: After handling items potentially contaminated with blood, body fluids, excretions, or secretions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 If continuation sheet Page 5 of 6 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 12/14/2022 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and manufacturer's instruction review, the facility failed to ensure an insulin pen was primed prior to administration. This resulted in a significant medication error. This affected one (Resident #21) of five residents reviewed for medication administration. The facility census was 22. Residents Affected - Few Findings include: Record review revealed Resident #21 was admitted on [DATE] with diagnoses including type two diabetes mellitus. During observation on 12/06/22 at 9:22 A.M., Licensed Practical Nurse (LPN) #183 prepared a Levimir insulin pen for Resident #21. She dialed up 10 units and administered the insulin to Resident #21. She did not prime the pen prior to administering the dose. During interview on 12/06/22 at 9:35 A.M., LPN #183 verified she did not prime the insulin pen prior to administering Resident #21 insulin. LPN #183 stated she does not know how to prime an insulin pen. Review of the Levemir flextouch pen-injector medication insert, dated 07/01/22, revealed priming your Levemir Flextouch Pen Turn the dose selector to select two units. Hold your pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows zero. A drop of insulin should be seen at the needle tip. If not change the needle and repeat the procedure no more than six times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365628 If continuation sheet Page 6 of 6