Health inspection·November 6, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a copy of the transfer or discharge notification to the Office of the State Long-Term Care Ombudsman for resident's discharges from the facility. This affected four (Resident #12, #32, #50 and #52) of four residents reviewed for discharge notification. The facility census was 54. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included hypoxemia, Alzheimer's disease, dementia in other diseases classified elsewhere and generalized anxiety disorder. Review of the quarterly Minimum Data Sets (MDS) assessment, dated 08/26/19, revealed the resident to be severely cognitively impaired. Review of the progress notes revealed the resident was discharged to the hospital for a mental status change on 05/14/19. Resident #12 was readmitted to the facility on [DATE]. There was no evidence the Office of the State Long-Term Care Ombudsman was notified of Resident #12's discharge to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 11/04/19 at 2:57 P.M. verified the Ombudsman was not notified of Resident #12's discharge to the hospital on [DATE]. 2. Record review revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included cellulitis/chronic ulcer with necrosis of muscle to the right lower extremity and osteomyelitis. Review of the nursing note, dated 10/02/19 at 10:17 P.M., revealed Resident #50 went out for an appointment for an anesthesia consult, and from his appointment Resident #50 was sent to hospital, due to a right lower extremity wound infection. There was no evidence the Office of the State Long-Term Care Ombudsman was notified of Resident #50's hospitalization. Interview with the DON on 11/04/19 at 3:57 P.M. verified the Ombudsman was not notified regarding the hospital stays. 3. Medical record review for Resident #32 revealed an admission date of 09/28/18. Diagnoses included end stage renal failure. Review of the facility's census revealed Resident #32 went out to the hospital on [DATE]. There was no evidence the Office of the State Long-Term Care Ombudsman was notified of Resident #32's Page 1 of 17 365813 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0623 hospitalization. Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 11/04/19 at 3:57 P.M. verified the Ombudsman was not contacted regarding the hospital stays. Residents Affected - Some 4. Medical record review for Resident #52 revealed an admission date of 06/17/19. Diagnoses included acute and chronic respiratory failure with hypoxia. Review of the progress notes, dated 09/19/19 and 09/22/19, revealed Resident #52 went out to the hospital. There was no evidence the Office of the State Long-Term Care Ombudsman was notified of Resident #52's hospitalization. Interview with the DON on 11/04/19 at 3:57 P.M. verified the Ombudsman was not contacted regarding the hospital stays. The DON stated the facility did not have a policy on notifying the Office of the State Long-Term Care Ombudsman when a resident was transferred from the facility. 365813 Page 2 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents received written bed hold notifications within 24 hours of their discharges from the facility. This affected four (Resident #12, #32, #50 and #52) of four residents reviewed for discharge notification. The facility census was 54. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included hypoxemia, Alzheimer's disease, dementia in other diseases classified elsewhere and generalized anxiety disorder. Review of the quarterly Minimum Data Sets (MDS) assessment, dated 08/26/19, revealed the resident to be severely cognitively impaired. Review of the progress notes revealed the resident was discharged to the hospital for a mental status change on 05/14/19. Resident #12 was readmitted to the facility on [DATE]. Review of Resident #12's record revealed there was no documentation that Resident #12 or Resident #12's representative were provided a written bed hold notification upon Resident #12's discharge to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 11/04/19 at 2:57 P.M. verified Resident #12 or Resident #12's representative did not receive a written bed hold notifications within 24 hours of Resident #12's discharge to the hospital on [DATE]. 2. Record review revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included cellulitis/chronic ulcer with necrosis of muscle to the right lower extremity and osteomyelitis. Review of the nursing note, dated 10/02/19 at 10:17 P.M., revealed Resident #50 went out for an appointment for an anesthesia consult, and from his appointment Resident #50 was sent to hospital, due to a right lower extremity wound infection. Further review of the resident's record revealed there was no evident the resident and/or resident's representative were given a bed hold notice within 24 hours of the resident's discharge to the hospital on [DATE]. Interview with the DON on 11/04/19 at 3:57 P.M. verified the facility did not send a notification of a bed hold to the resident and/or resident's representative. 3. Medical record review for Resident #32 revealed an admission date of 09/28/18. Diagnoses included end stage renal failure. Review of the facility's census revealed Resident #32 went out to the hospital on [DATE]. Further review of the resident's record revealed there was no evident the resident and/or resident's representative were given a bed hold notice within 24 hours of the resident's discharge to the hospital on [DATE]. Interview with the DON on 11/04/19 at 3:57 P.M. verified the facility did not send a notification 365813 Page 3 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0625 of a bed hold notice to the resident and/or resident's representative when discharged to the hospital. Level of Harm - Minimal harm or potential for actual harm 4. Medical record review for Resident #52 revealed an admission date of 06/17/19. Diagnoses included acute and chronic respiratory failure with hypoxia. Residents Affected - Some Review of the progress notes, dated 09/19/19 and 09/22/19, revealed Resident #52 went out to the hospital. Further review of the resident's record revealed there was no evident the resident and/or resident's representative were given a bed hold notice within 24 hours of the resident's discharge to the hospital on [DATE] and 09/22/19. Interview with the DON on 11/04/19 at 3:57 P.M. verified the facility did not send a notification of a bed hold to the resident and/or resident's representative. The interview further revealed she didn't have a policy for bed holds and followed the regulation. 365813 Page 4 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide residents and their representatives with a summary of the baseline care plan. This affected two (Resident #26 and #155) of four residents reviewed for baseline care plans that were admitted within the past year. The facility census was 54. Findings include: 1. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, cognitively communication deficit, major depressive disorder, muscle weakness, hypertensive heart disease without heart failure, acute bronchitis, apraxia, contracture of muscle, type two diabetes mellitus, psychotic disorder with delusions due to known physiological condition, vitamin deficiency and history of falling. Review of the baseline care plan revealed the resident's baseline care plan was completed on 12/22/18. There was no documentation that a written summary of Resident #26's baseline care plan was provided to the resident or resident's representative. Interview with the Director of Nursing (DON) on 11/04/19 at 2:57 P.M. verified Resident #26's medical record contained no documentation that Resident #26 or Resident #26's representative was given a written summary of the baseline care plan. 2. Record review for Resident #155 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hyperlipidemia, dysphagia, occlusion and stenosis of unspecified carotid artery, other abnormalities of gait and mobility, essential hypertension, muscle weakness, atherosclerotic heart disease of native coronary artery with angina pectoris, conductive and sensorineural hearing loss, chronic kidney disease, type two diabetes mellitus and personal history of other malignant neoplasm of skin. Resident #155 discharged from the facility to the hospital on [DATE]. Review of the baseline care plan revealed the resident's baseline care plan was completed on 08/20/19. There was no documentation that a written summary of Resident #155's baseline care plan was provided to the resident or resident's representative. Interview with the Director of Nursing (DON) on 11/04/19 at 2:57 P.M. verified Resident #155's medical record contained no documentation that Resident #155 or Resident #155's representative was given a written summary of Resident #155's baseline care plan. 365813 Page 5 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and staff interview, the facility failed to ensure a resident's fall risk was assessed and fall interventions were in place to prevent falls. This affected one (Resident #43) of two residents reviewed for accidents. The facility census was 54. Findings include: Record review for Resident #43 revealed the resident was admitted to the facility on [DATE]. Diagnoses included idiopathic gout, Parkinson's disease, dementia with behavioral disturbance, muscle wasting and atrophy, difficulty in walking, cognitive communication deficit and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/05/19, revealed the resident to be severely cognitively impaired and required extensive assistance from staff with bed mobility, transfers and toileting. Resident #43 was reported to have two or more falls with no injury and two or more falls with injury. Review of Resident #43's chart revealed no fall risk assessments completed to assess the resident's risk for falls. Review of the fall care plan, initiated on 04/18/19, revealed the resident to be at risk for falls and fall related injuries due to the resident having a history of falls. Interventions included placing a dycem to the resident's wheelchair. On 05/06/18, a dycem to the resident's recliner was added as an intervention to the plan of care. Review of Resident #43's chart revealed resident fell on [DATE], 05/06/19, 06/12/19, 06/22/19, 07/08/19, 07/11/19, 07/31/19, 08/15/19, 10/04/19 and 10/05/19. Review of Resident #43's progress notes revealed the resident fell on [DATE] and was noted to be kneeling with his forehead on the floor in the dining room. A head-to-toe assessment and vital signs were completed. Resident #43 was observed with bruising and redness to the forehead that was a size of a silver dollar. It was noted the resident's dycem to his wheelchair was not in place at the time of the fall and staff were educated on the importance of proper use of dycem for fall prevention. The progress note, dated 10/05/19, revealed the resident fell and was noted to be laying on his left side with his forehead on the floor on the secured unit. A head-to-toe assessment and vital signs were completed. Resident #43 was observed to have redness, swelling and bleeding noted to his forehead. Resident #43 also had a quarter size lump on the left side of his forehead with a small cut. Resident #43's cut was cleaned and steri strips were applied. It was noted Resident #43's dycem was not in place at the time of the fall and staff were educated on the importance of proper use of dycem for fall prevention. Interview with the Director of Nursing (DON) on 11/06/19 at 10:35 A.M. revealed Resident #43 fell on [DATE] in the dining room. Resident was observed to have bruising to his forehead. The DON verified Resident #43 did not have dycem in his wheelchair at the time of the fall. The DON also reported Resident #43 fell on [DATE] and was found on his left side. The DON also verified Resident #43's dycem was not in place in the recliner at the time of the fall. Subsequent interview with the DON on 365813 Page 6 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0689 11/06/19 at 4:00 P.M. verified the facility did not have any fall risk assessments completed for Resident #43. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Falls policy, dated November 2013, revealed fall risk assessments were to be completed upon admission, quarterly and with each fall. Residents Affected - Few 365813 Page 7 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and staff interview, the facility failed to ensure the drug regimen review recommendations were appropriately addressed by the attending physician in a timely manner and failed to ensure the physician documented their rationale for not changing a resident's medications as indicated in a pharmacy recommendation. This affected one (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cognitive communication deficit, major depressive disorder, dementia in other diseases classified elsewhere and insomnia. Review of the annual Minimum Data Set (MDS) assessment, dated 10/10/19, revealed the resident to be severely cognitively impaired. Review of the physician orders revealed the resident was prescribed Seroquel 100 milligrams (mg.) at bedtime for dementia in other diseases classified elsewhere with behavioral disturbance on 11/12/18, Seroquel 50 mg. two times per day for dementia in other diseases classified elsewhere with behavioral disturbance on 11/28/19, and Zoloft 50 mg. one time per day for major depressive disorder on 11/28/18. Review of the pharmacy recommendation, dated 04/02/19, revealed Resident #44 to be prescribed Seroquel 50 mg. two times per day, Seroquel 100 mg. at bedtime and Zoloft 50 mg. per day. The pharmacy recommendation stated the physician should consider a trial reduction or document if the medications were clinically contraindicated. Further review of the pharmacy recommendation revealed Resident #44's physician marked that the physician disagreed with the recommendation and indicated no changes in the comments section of the pharmacy recommendation form on 05/06/19. The pharmacy recommendation did not include a rationale for not changing Resident #44's Seroquel 50 mg. two times per day, Seroquel 100 mg. at bedtime and Zoloft 50 mg. per day. Review of the pharmacy recommendation, dated 10/01/1,9 revealed Resident #44 to be prescribed Seroquel 50 mg. two times per day, Seroquel 100 mg. at bedtime and Zoloft 50 mg. per day. The pharmacy recommendation stated the physician should consider a trial reduction or document if the medications were clinically contraindicated. Further review of the pharmacy recommendation revealed Resident #44's physician marked that the physician disagreed with the recommendation and indicated resident to be under psychiatric care in the comments section of the pharmacy recommendation form. The pharmacy recommendation was signed by Resident #44's physician on 10/07/19. Record review revealed there was no documentation in regarding the resident being seen by a psychiatrist. There was no documentation from the resident's physician to indicate a gradual dose reduction of the Seroquel 50 mg. two times per day, Seroquel 100 mg. at bedtime and Zoloft 50 mg. per day were contraindicated. Interview with the Director of Nursing (DON) on 11/04/19 at 2:57 P.M. verified Resident #44's pharmacy recommendation dated 04/02/19 was not addressed by the physician until 05/06/19. The DON also verified Resident #44's pharmacy recommendation dated 04/02/19 did not include a rationale for not changing Resident #44's Seroquel 50 mg. two times per day, Seroquel 100 mg. at bedtime and Zoloft 50 365813 Page 8 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0756 Level of Harm - Minimal harm or potential for actual harm mg. per day. The DON verified the facility did not have a policy regarding the timeframes of the different steps in the medication regimen review process. Interview with Consultant Pharmacist #600 on 11/05/19 at 2:44 P.M. verified Resident #44 was not seen by a psychiatrist. Residents Affected - Few Review of the Tapering Medications and Gradual Drug Reduction policy, dated 11/05/19, revealed residents who use antipsychotic drugs shall receive gradual dose reductions unless clinically contraindicated. The physician must document the clinical rationale for why any additional attempted dose reduction would likely impair the resident's function or increase distress behavior. 365813 Page 9 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents on psychotropic medications received gradual dose reductions unless contraindicated. The facility also failed to ensure as needed psychotropic medication orders were limited to 14 days or that a rationale and duration of the as needed psychotropic medication was indicated in the medical record. This affected three (Resident #2, #15 and #43) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: 1. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance and anxiety disorder. Review of the quarterly Minimum Data Sets (MDS) assessment, dated 10/05/19, revealed the resident to be severely cognitively impaired. Review of the physician orders, dated 07/23/19, revealed the resident was prescribed Ativan 0.5 milligrams (mg.) every 12 hours as needed for anxiety and agitation related to generalized anxiety disorder. There was no documentation of a rationale and duration of Resident #43's Ativan 0.5 mg. every 12 hours as needed for anxiety and agitation related to generalized anxiety disorder prescribed after 07/23/19. Interview with Consultant Pharmacist #600 on 11/05/19 at 2:34 P.M. verified Resident #43's Ativan 0.5 mg. every 12 hours as needed for anxiety and agitation related to generalized anxiety disorder prescribed on 07/23/19 was not limited to 14 days and Resident #43's chart did not have a rationale and duration of the as needed Ativan documented in the medical record. 2. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression. Review of the quarterly MDS assessment, dated 09/03/19, revealed the resident #15 had severe cognitive deficits. Review of the physician orders, dated 10/07/19, revealed an order to administer Ativan 0.5 mg. every four hours as needed with no stop date for review. Review of Medication Administration Record, dated 10/07/19 through 11/06/19, revealed Resident #15 received only two doses of Ativan 0.5 mg. on 10/10/19 and 10/16/19. Interview with the Director of Nursing (DON) on 11/05/19 at 9:48 A.M. confirmed the Ativan for Resident #15 should have a stop date within the 14 days or the physician was supposed to evaluate it and continue if needed. She stated she has only been at the facility for six weeks and knew this was a problem that needed fixed. The interview further revealed there wasn't a policy for unnecessary medications that the regulation was followed. 3. Record review for Resident #2 revealed the resident was admitted on [DATE]. Diagnoses included anxiety. Review of the quarterly MDS assessment, dated 08/02/19, revealed the resident was moderately cognitively impaired. 365813 Page 10 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0758 Level of Harm - Minimal harm or potential for actual harm Review of the physician orders, dated 10/31/18, revealed the resident was to receive Ativan 0.5 mg. sublingually every four hours as needed for anxiety disorder. Review of the resident's physician notes from 01/21/19 through 11/05/19 revealed the Ativan was not addressed. Residents Affected - Some Interview with the Director of Nursing (DON) on 11/05/19 at 9:48 A.M. confirmed the Ativan for Resident #2 should have a stop date within the 14 days or the physician was supposed to evaluate it and continue if needed. She stated she has only been at the facility for six weeks and knew this was a problem that needed fixed. The interview further revealed there wasn't a policy for unnecessary medications that the regulation was followed. 365813 Page 11 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

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, medical record review, and staff interview, the facility failed to ensure medication error rate was less than five percent. There were 29 opportunities with two medication errors for an error rate of 6.9 percent (%). This affected one (#15) of six residents reviewed for observation of medication administration. The facility census was 54. Residents Affected - Few Findings include: Medical record review for Resident #15 revealed an admission date of 05/01/18. Diagnoses included heart failure. Review of the physician orders for Resident #15 revealed there were not any current orders dated 10/01/19 through 11/05/19 for Cymbalta or Potassium. Observation of medication administration to Resident #15 on 11/05/19 at 8:35 A.M. revealed Licensed Practical Nurse (LPN) #22 administered Cymbalta 60 milligram (mg.) and Potassium 10 milliequivalent (meq.). This was observed on the computer screen the LPN was looking at for the resident and the drugs were also included in the packet from the pharmacy which was labeled for Tuesday at 8:00 A.M. A total of 29 opportunities was observed for medication administration. Interview with LPN #22 on 11/05/19 at 10:45 A.M. verified there wasn't an order for Cymbalta and Potassium for Resident #15 and didn't know why they were on her Medication Administration Record or on the packages from the pharmacy. 365813 Page 12 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure insulin vials were not expired. This affected one (Resident #1) of six residents reviewed for medication administration. The facility identified there were four residents who received insulin and resided on the 200 hallway. The facility census was 54. Findings include: Observation of administration of Novolog on [DATE] at 10:41 A.M. to Resident #1 revealed Registered Nurse (RN)) #26 took the Novolog vial out of the drawer of the medication cart to draw up insulin and upon checking the date, it said the opening date was [DATE]. The RN went to the refrigerator to pull Novolog to administer it to Resident #1 and the open date was [DATE] and the RN went to get another one which was Novolin R out of the refrigerator and it was dated [DATE]. Interview with RN #26 on [DATE] at 11:18 A.M. verified the above vials were out of date and should have been discarded after 28 or 42 days of open date. Review of the facility's policy titled Expiration Dates of Common Medications, dated [DATE], revealed Novolog vial should be dated at the time of opening and discarded within 28 days. Further review revealed Novolin R vial should be dated at the time of opening and discarded within 42 days. 365813 Page 13 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident code statuses documented in physician progress notes were accurate. The facility also failed to document a resident's transfer to the hospital in the medical record. This affected three (Resident #26, #32 and #44) of 16 residents reviewed for complete and accurate medical records. The facility census was 54. Findings include: 1. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, hypertensive heart disease without heart failure, type two diabetes mellitus and psychotic disorder with delusions due to known physiological condition. Review of the annual Minimum Data Set (MDS) assessment, dated 10/26/19, revealed the resident to be severely cognitively impaired. Review of the resident's chart revealed the resident to have an appendix A form indicating her code status to be a Do Not Resuscitate Comfort Care (DNRCC). Resident #26's DNRCC appendix A form was signed by Resident #26's physician on 12/24/18. Review of Resident #26's physician's progress notes dated 09/23/19, 08/19/19, 07/17/19, 07/03/19, 06/17/19, 05/01/19, 03/25/19, 02/18/19 and 02/11/19 revealed the physician to document Resident #26's code status to be a full code. Interview with the Director of Nursing (DON) on 11/04/19 at 2:57 P.M. verified Resident #26's physician's progress notes dated 09/23/19, 08/19/19, 07/17/19, 07/03/19, 06/17/19, 05/01/19, 03/25/19, 02/18/19 and 02/11/19 inaccurately documented Resident #26's code status to be a full code. 2. Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, dementia in other diseases classified elsewhere, type two diabetes mellitus and personal history of pulmonary embolism. Review of the annual Minimum Data Sets (MDS) assessment, dated 10/10/19, revealed the resident to be severely cognitively impaired. Review of the resident's chart revealed the resident to have an appendix A form indicating her code status to be a Do Not Resuscitate Comfort Care (DNRCC). Resident #26's DNRCC appendix A form was signed by Resident 44's physician on 10/17/18. Review of Resident #44's physician's progress notes dated 01/21/19, 03/27/19, 04/17/19, 05/08/19, 05/20/19, 07/01/19, 07/10/19 and 09/11/19 revealed the physician to document Resident #44's code status to be a full code. Interview with the Director of Nursing (DON) on 11/04/19 at 2:57 P.M. verified Resident #44's physician's progress notes dated 01/21/19, 03/27/19, 04/17/19, 05/08/19, 05/20/19, 07/01/19, 07/10/19 and 09/11/19 inaccurately documented Resident #44's code status to be a full code. 3. Medical record review for Resident #32 revealed an admission date of 09/28/18. Diagnoses included end stage renal failure. 365813 Page 14 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0842 Review of the census revealed Resident #32 went out to the hospital on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes, dated 10/25/19, revealed they were silent for the reason why the resident went to the hospital on this date. Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #14 on 11/04/19 at 2:56 P.M. revealed he took care of Resident #32 on 10/25/19. He stated she left at 5:00 A.M. for dialysis and didn't return. He stated at the end of his shift at 6:30 P.M. he called the dialysis center and they reported they had sent her to the hospital. He verified he didn't put a note in the charting, because it was the end of his shift. 365813 Page 15 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and policy review, the facility failed to have maintain accurate infection control tracking and logging. This affected nine residents ((#10, #12, #20, #34, #41, #42, #49, #50 and #152) and the had the potential to affect all 54 residents residing in the facility. Residents Affected - Many Findings include: Record review of the facility's Minimum Data Set Matrix revealed nine residents (#10, #12, #20, #34, #41, #42, #49, #50 and #152) were identified by the facility as having an active infection. Review of the facility's infection control log for the last 12 months revealed there was no evidence of tracking or logging infections for the months of 09/2019 and 10/2019. Interview on 11/06/19 at 1:46 P.M. with the Administrator and the Director of Nursing (DON) verified that the facility has not been appropriately tracking and logging infections for the months of 09/2019 and 10/2019. Review of the facility's undated policy titled Infection Control Policy revealed the Unit Managers are to review the yellow order duplicates daily for infection control concerns, then log the information on the Infection Control Screening Tool, and any infection issue that meets the given criteria will be logged into an Infection Control spreadsheet for analysis. 365813 Page 16 of 17 365813 11/06/2019 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and policy review, the facility failed to have an Antibiotic Stewardship Program in place. This affected ten residents (#10, #17, #21, #28, #32, #34, #45, #48, #50 and #152) and had the potential to affect all 54 residents residing in the facility. Residents Affected - Many Findings include: Record review of the facility's Minimum Data Set Matrix revealed ten residents (#10, #17, #21, #28, #32, #34, #45, #48, #50 and #152) were identified by the facility as receiving antibiotics. Review of the facility's infection control binder revealed there was no antibiotic tracking. Interview on 11/06/19 at 1:46 P.M. with the Administrator and the Director of Nursing (DON) verified they were supposed to be using McGreer's Definitions of Infections for Long Term Care Facilities. However, they verified there was no evidence of the program. Review of the facility's undated Antibiotic Stewardship Program policy revealed the facility is committed to improving the use of antibiotics to optimize the treatment of infections while reducing the danger of antibiotic resistance. 365813 Page 17 of 17