Health inspection·June 15, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on record review, observation, staff interview, review of the facility policy and review of the employee handbook, the facility failed to provide feeding assistance to residents in a dignified and respectful manner. This affected one (#13) of five facility-identified residents who were dependent on staff for assistance with eating. The census was 51. Findings include: Review of the medical record for Resident #13 revealed an admission date of 03/05/22 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #13 dated 03/11/22 revealed the resident had severe cognitive impairment and was totally dependent on the assistance of one staff with eating. Review of the care plan for Resident #13 dated 05/19/22 revealed the resident has an activities of daily living (ADL) self-care performance deficit related to dementia with behaviors, fibromyalgia, Alzheimer's, convulsions, restlessness and agitation and falls. The resident required extensive assistance by staff to eat. Observation on 06/09/22 at 8:12 A.M. revealed State Tested Nursing Assistant (STNA) #231 was seated next to Resident #13's bed and was feeding her breakfast with one hand while looking at the internet on her personal cell phone. Interview on 06/09/22 at 8:12 A.M. with STNA #231 confirmed she was feeding Resident #13 and was checking a website on her personal cell phone at the same time. Interview on 06/09/22 at 1:00 P.M. with the Administrator the facility did not have a policy specific to the use of cell phones, but it was addressed in the employee handbook. Administrator confirmed it was not appropriate for staff to look at their personal cell phones while providing resident care. Review of the facility policy titled Resident Rights dated May 2020 revealed the residents had the right to be treated with dignity and respect. Review of the facility Employee Handbook dated 11/01/12 revealed employees are prohibited from using personal cellular telephones and electronic devices anytime during the work day unless they were on a lunch break. Page 1 of 19 365813 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure the residents code status was accurately documented on the resident's chart. This affected one (#19) out of three residents reviewed for advance directives. The facility census was 51. Findings included: Record review for Resident #19 revealed she was admitted to the facility on [DATE]. Diagnosis included atrial fibrillation, dementia, gastroesophageal reflux disease, transient ischemic attack, muscle weakness, asthma, kidney disease stage three, anemia, hypotension, and Alzheimer's disease. Review of the quarterly minimum data set (MDS) assessment, dated 04/01/22, revealed Resident #19 had impaired cognition as evidenced by her brief interview for mental status (BIMS) score of 10. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, personal hygiene, and supervision from staff with eating. Further review of the hard chart for Resident #19 revealed she was marked as a full code advance directive on chart located at the nurse's station on the resident unit. Review of the nursing progress notes for Resident #19 revealed a progress note, dated 05/25/22, indicating nurse practitioner (NP) in with new order: do-not-resuscitate (DNRCC). Review of Resident #19 physician orders revealed an order for a DNRCC advanced directive ordered on 05/25/22. Review of the form titled, DNR Comfort Care, dated 06/01/22, revealed Resident #19 was a DNRCC comfort care effective 06/01/22 along with a physician signature dated 06/01/22. Interview on 06/07/22 at 8:39 A.M. with registered nurse (RN) #526 confirmed Resident #19's medical chart at the nurse's station indicated Resident #19 was a full code. However, RN #526 confirmed the progress notes revealed Resident #19 was a DNRCC effective 05/25/22 and the DNR form was dated 06/01/22. Review of the facility policy titled, DNR Protocol, dated 01/26/13, revealed a DNR order change should be updated in the resident's chart. If a DNR order is changed from one of three types of DNR orders to a different type, the residents medical record should be revised. 365813 Page 2 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure the facility developed care plans for resident care needs regarding resting hand splints and oxygen therapy. This affected two (#26 and #152) of 13 residents reviewed for care plans. The facility census was 51. Findings include: 1. Resident #26 admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified hemiplegia affecting non-dominant left side, history of traumatic brain injury, unspecified cerebrovascular disease, type II diabetes, unspecified anxiety disorder, unspecified major depressive disorder, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact, no behaviors, no wandering, and did not reject care. Resident #26 was a two-person assist and required extensive assist with all ADL's. Resident #26 had functional limitation in range of motion to one side. Review of the medical record revealed Resident #26 had physician orders on 04/07/2022 for resting hand splint to left hand for six hours per day every day shift. Review of care plan dated 05/25/2022 revealed Resident #26 did not have a care plan for contracture care with resting hand splints. Observation on 06/06/2022 at 2:11 P.M. revealed Resident #26 was unable to move his left arm and the left had rested on the bed with fingers curled inward towards the resident's palm. Resident #26 not wearing his resting hand splint, and the splint visible in top drawer of the clear plastic chest of drawers. Interview on 06/08/22 at 12:26 P.M. the Director of Nursing (DON) confirmed Resident #26's care plan did not address his contracture or resting left hand splint. 2. Resident #152 admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified systolic heart failure, acute respiratory failure with hypoxia, hypertension, type II diabetes, unspecified depression, unspecified anxiety disorder, and chronic pulmonary edema. Review of most recent MDS assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #152 was on oxygen and received Hospice Care services. The resident was a two-person physical assist and required extensive assistance with all Activities of Daily Living (ADL's). Review of Care plan dated 06/07/2022 revealed Resident #152's care plan did not address oxygen administration. Observation on 06/06/22 10:37 A.M. revealed Resident #152 was seated in bed with head elevated and wore oxygen at three Liters per minute per nasal cannula. 365813 Page 3 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0656 Interview on 06/08/22 at 12:10 P.M. the DON verified Residents #152's care plan did not include oxygen administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365813 Page 4 of 19 365813 06/15/2022 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. Based on record review, staff interview, and facility policy, the facility failed to complete a thorough and accurate fall investigation. This affected one (#40) out of three residents reviewed for falls. The facility census was 51. Findings include: Review of the medical record for Resident #40 revealed an admission date of 06/17/21. Diagnoses included dementia, Coronavirus Disease 2019 (COVID-19), amnesia, generalized anxiety disorder, and schizoaffective. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #40, dated 01/21/22, revealed the resident had impaired cognition. Resident #40 had a brief interview of mental status (BIMS) score of 99, indicating the resident chose not to respond. The resident required extensive assistance for hygiene, toileting, dressing, transfer, and bed mobility. Resident #40 required supervision for walking in the room/corridor, locomotion on/off the unit, and eating. No hallucination, delusions, or rejection of care were noted on the assessment. Review of the Morse Fall Scale Assessment for Resident #40 dated 09/01/21 revealed the resident was at a moderate risk for falls. Review of the plan of care for Resident #40 dated 09/02/21 revealed the resident was at risk for falls and fall related injuries due to dementia, amnesia, anxiety disorder, and schizoaffective disorder. Interventions included maintaining bed in lowest position when occupied, assisting with toileting needs and incontinence care on routine rounds, and providing and assisting resident with wearing appropriate footwear. Review of the nursing note for Resident #40 dated 02/06/22 at 9:17 A.M. revealed at about 11:18 P.M. on 02/05/22, the aide reported to the writer she heard a loud noise and was not sure of the room it came from at the time. Writer went with the aide, and we found this resident on the floor on her left side with head raised but facing down. Resident #40 was holding her forehead and leaning on her left elbow in another resident's room. Resident #40 busted into tears and unable to explain how she fell. Aide assisted writer in getting resident off the floor to her chair. Upon raising her head, Resident #40 was bleeding from her nose and mouth. A huge swelling was noted on resident's forehead. Writer tried applying ice and wiping resident's nose and mouth but resident uncooperative. Vital signs taken: blood pressure 165/113; pulse 78; temperature 98.1 degrees Fahrenheit; oxygen saturation 98%. Resident #40 was offered her favorite drink and continued to sip her drink. Also, resident continued to be uncooperative. Physician and family notified, and resident was sent to local hospital on a stretcher after 1:00 A.M. on 02/06/22. Resident #40 was returned to the facility at 5:48 A.M. on 02/06/22. Hospital staff called and reported resident had some blood clots from fall and middle broken bone. Treating with antibiotic. Review of the hospital paperwork for Resident #40 dated 02/06/22 revealed the resident had a fracture to the left third toe and a small hairline fracture to the maxillary sinus and sphenoid sinus. Resident #40 also had a left frontal hematoma. The hospital paperwork revealed orders to buddy tape the left third toe for approximately two weeks. The facility was to start the resident on Augmentin twice daily for seven days related to the fractures noted to the face. Resident #40 required a 365813 Page 5 of 19 365813 06/15/2022 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 pressure dressing to the head daily for the next five to seven days to assist with wound healing related to the left frontal hematoma. Review of the physician orders for Resident #40 in February 2022 revealed orders for the buddy taping of the toes and the Augmentin for one week. No order was noted related to the pressure dressing to the head for 5 to 7 days. Review of the facility assessments for Resident #40 revealed no fall assessment was completed after the fall on 02/05/22. Review of the facility incident report for Resident #40 dated 02/06/22, revealed no fall interventions put into place. Interview on 06/08/22 at 10:00 A.M. with the Director of Nursing (DON) confirmed there was no fall assessment completed for Resident #40 following her fall on 02/05/22. The DON also confirmed there was no order for a pressure dressing to the head as indicated by the hospital paperwork on 02/06/22. The facility did not complete a thorough investigation and there was no explanation of what occurred to Resident #40 to cause the fall on the night of 02/05/22. Review of the facility policy titled Falls Policy dated 03/2016 revealed the facility failed to follow the policy. According to the policy a fall risk assessment will be completed upon admission, quarterly, and with each fall. Immediate interventions will be initiated. This deficiency substantiates Complaint Number OH00112705. 365813 Page 6 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

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 medical record review, observations, staff interview, and policy review, the facility failed to ensure residents had active physician orders to receive oxygen therapy and to ensure residents oxygen tubing was labeled and dated. This affected three (#152, #30, and #252) out of eight residents residing in the facility who received oxygen therapy. The facility census was 51. Residents Affected - Few Findings include: 1. Resident #30 admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD), acute diastolic congestive heart failure, d unspecified acute kidney failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #30 received oxygen therapy. Resident #30 required supervision and setup assistance for eating and extensive two-staff assistance with all other Activities of Daily Living (ADL's). Review of care plan dated 05/03/22 revealed Resident #30 had COPD related to physiological atrophy. Interventions included keep the head of bed elevated and Oxygen at 2.5 Liters per minute per nasal cannula. Review of the medical record revealed Resident #30 had no current physician orders for oxygen use. Resident #30 had physician orders for oxygen at two liter per minute per nasal cannula with padded ear protection written on 04/21/2022 and discontinued on 06/02/22 and an order to change and date tubing every Tuesday on day shift written 05/17/22 and discontinued on 06/02/22. The medical record review for Resident #30 revealed there was no current or active order for oxygen administration. Observation on 06/06/22 at 10:49 A.M. revealed Resident #30 wore a nasal cannula and oxygen was set at 2.5 Liters per minute. The oxygen tubing was not labeled or dated. Interview on 06/06/22 at 10:57 A.M. State Tested Nurse Aide (STNA) #238 verified Resident #30's oxygen tubing was not labeled or dated. Interview on 06/06/22 at 11:00 A.M. Licensed Practical Nurse (LPN) #126 stated night shift was assigned to change oxygen tubing once weekly and tubing was supposed to be labeled and dated. Interview on 06/08/22 10:20 AM Administrator and Director of Nursing (DON) verified there were no active physician orders for oxygen for Residents #30. The order for Resident #30's oxygen was discontinued when she was sent to the hospital on [DATE] and was not restarted when she returned to facility. 2. Resident #152 admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified systolic heart failure, acute respiratory failure with hypoxia, hypertension, type II diabetes, unspecified depression, unspecified anxiety disorder, and chronic pulmonary edema. Review of most recent MDS assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #152 was on oxygen and 365813 Page 7 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few received Hospice Care services. The resident was a two-person physical assist and required extensive assistance with all Activities of Daily Living (ADL's). Review of the medical record revealed Resident #152 had no active physician orders for oxygen. Review of the medical record revealed Baseline Care Plan dated 05/26/22 indicated Resident #152 was not receiving oxygen therapy while a resident. Review of Care plan dated 06/07/22 revealed Resident #152 had no care plan for oxygen therapy. Observation on 06/06/22 10:37 A.M. revealed Resident #152 was seated in bed with head elevated and wore oxygen at three Liters per minute per nasal cannula. The oxygen tubing tubing was not labeled or dated. Interview on 06/06/2022 at 10:57 A.M. STNA #238 verified Resident #152's oxygen tubing was not labeled or dated. Interview on 06/08/22 at 10:20 A.M. the Administrator and DON verified there were no active physician orders for oxygen for Resident #152. Resident #152 was ordered oxygen from Hospice on 05/25/2022 and the order was not transcribed. Interview on 06/08/22 at 12:27 P.M. the DON stated oxygen tubing was to be changed weekly and should be initialed and labeled with the date applied. 3. Review of the medical record for Resident #252 revealed an admission date of 03/25/22. Diagnoses included gastroesophageal reflux disease, retention of urine, pneumonia, pressure ulcer to sacrum and right heel, hyperglycemia, weakness, anemia, and type II diabetes mellitus. Review of the significant change MDS assessment for Resident #252, dated 05/26/22, revealed the resident had an impaired cognition. Resident #252 had a brief interview of mental status (BIMS) score of five. The resident required total dependence for toileting, eating, and locomotion on/off the unit. Resident #252 required extensive assistance from staff for bed mobility, transfers, dressing, and hygiene. No hallucination, delusions, or rejection of care were noted on the assessment. The assessment indicated the usage of oxygen while a resident. Review of the plan of care for Resident #252 dated 06/06/22 revealed the resident had oxygen therapy related to ineffective gas exchange. No interventions were listed by the facility. Observations on 06/06/22 at 11:00 A.M. of Resident #252 revealed the resident was laying in bed with her nasal cannula in both nostrils of her nose. The oxygen was set at two liters/minute and flowing from the oxygen concentrator which was turned on. Review of the readmission assessment dated [DATE] for Resident #252 revealed the resident was on oxygen coming from the hospital. Review of the physician orders for Resident #252 in May 2022 revealed no current orders for oxygen therapy. Review of vital signs for Resident #252 in May 2022 revealed oxygen saturation within normal limits. 365813 Page 8 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/08/22 at 2:00 P.M. with the Administrator confirmed that Resident #252 did not have any current orders for oxygen therapy. Review of the facility policy titled Oxygen Administration dated 08/01/19 revealed the facility failed to follow their policy. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 365813 Page 9 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was present for eight consecutive hours on 04/30/22, 05/08/22, 05/27/22, 05/28/22, 06/04/22, and 06/05/22. This had the potential to affect all 51 residents residing in the facility. The census was 51. Findings include: Review of staffing sheets dated 04/30/22, 05/08/22, 05/28/22, and 06/04/22 revealed there was not an RN scheduled on any of the dates. Review of the staffing sheet for 05/27/22 revealed an RN was scheduled for only three consecutive hours. Review of the staffing sheet for 06/05/22 revealed there was not an RN scheduled on 06/05/22. Review of signed statement per the Director of Nursing (DON) dated 06/09/22 revealed the DON was present in the facility for six consecutive hours on 06/05/22. Interview on 06/09/22 at 11:00 A.M. with the DON confirmed she was present in the facility for six consecutive hours on 06/05/22 and the facility did not have an RN present for eight hours on this date. Interview on 06/08/22 at 4:20 P.M. with the Administrator confirmed the facility did not have a RN working in the facility for eight consecutive hours on 04/30/22, 05/08/22, 05/27/22, 05/28/22, 06/04/22, and 06/05/22. Administrator further confirmed the facility did not have a written policy regarding staffing. This deficiency substantiates Complaint Number OH00132613 and OH00112705. 365813 Page 10 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

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 medical record review, review of staffing schedules, staff interview, and review of the facility policy, the facility failed to ensure medications were administered as ordered by the attending physician. This affected four (#11, #21, #26 and #13) of six residents reviewed for medications. The facility census was 51. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 03/20/18 with diagnoses including spinal stenosis and schizoaffective disorder. Review of the Minimum Data Set (MDS) for Resident #11 dated 02/27/22 revealed resident was cognitively impaired and required supervision and physical assistance of one staff with activities of daily living (ADL's.). Review of the April 2022 Medication Administration Record (MAR) for Resident #11 revealed the following medications were left blank in the MAR on 04/30/22: Ativan one milligram (mg) due at 10:00 P.M., Gabapentin 100 mg due at 8:00 P.M. Review of the nurse progress notes for Resident #11 dated 04/30/22 and 05/01/22 revealed the notes contained no documentation regarding omission of evening medications for resident on 04/30/22. 2. Review of the medical record for Resident #21 revealed an admission date of 09/15/20 with a diagnosis of chronic obstructive pulmonary disease (COPD.) Review of the MDS for Resident #21 dated 04/01/22 revealed resident was cognitively impaired and required supervision with ADL's. Review of the April 2022 Medication Administration Record (MAR) for Resident #21 revealed the following medications were left blank in the MAR on 04/30/22: Remeron 30 mg due at 8:00 P.M., Seroquel 12.5 mg due at 8:00 P.M., Tylenol 1000 mg due at 8:00 P.M., Ativan 0.5 mg due at 8:00 P.M. Review of the nurse progress notes for Resident #21 dated 04/30/22 and 05/01/22 revealed the notes contained documentation regarding omission of evening medications for resident on 04/30/22. 3. Review of the medical record for Resident #26 revealed an admission date of 03/02/11 with a diagnosis of hemiplegia. Review of the MDS for Resident #26 dated 04/04/22 revealed resident was cognitively impaired and required extensive assistance of two staff with ADL's. Review of the April 2022 Medication Administration Record (MAR) for Resident #26 revealed the following medications due at 8:00 P.M. were left blank in the MAR on 04/30/22: Atorvastatin 10 mg, Baclofen 10 mg, Gabapentin 500 mg, Keppra 500 mg, Latanoprost eye drops, Lyrica 75 mg, Metformin 1000 mg, oxycodone five mg. Review of the nurse progress notes for Resident #26 dated 04/30/22 and 05/01/22 revealed the notes 365813 Page 11 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0755 contained no documentation regarding omission of evening medications for resident on 04/30/22. Level of Harm - Minimal harm or potential for actual harm Review of the staffing schedule for 04/30/22 revealed there was one nurse working in the facility for the shift beginning at 6:00 P.M. on 04/30/22 and ending at 6:00 A.M. on 05/01/22, Licensed Practical Nurse (LPN) # 126. Residents Affected - Some Interview on 06/08/22 at 3:22 P.M. with LPN #126 confirmed he was called in to work from 6:00 P.M. on 04/30/22 to 6:00 A.M. on 05/01/22. LPN # 126 further confirmed he usually worked day shift and he was the only nurse working in the facility that caring for 48 residents. LPN #126 confirmed he tried his best to get all the medications administered but where there were blanks in the MAR it was because he wasn't able to administer the medication. LPN #126 confirmed he noted when giving report to the oncoming shift that not all medications were administered. LPN #126 confirmed he did not document which residents did not receive their medications, and he only documented in the MAR's for the medications he actually administered. Interview on 06/08/22 at 4:20 P.M. with the Administrator confirmed LPN #126 worked in the facility by himself from 6:00 P.M. on 04/30/22 until 6:00 A.M. on 05/01/22. Administrator further confirmed the facility usually staffed three nurses on nightshift, but they had call offs and were unable to get anyone to come in to assist LPN #126. Administrator confirmed the facility did not have a written policy regarding staffing. Review of the facility policy titled Medication Administration undated revealed licensed staff would administer medications as ordered by the physician. 4. Review of the medical record for Resident #13 revealed an admission date of 03/05/22 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the MDS for Resident #13 dated 03/11/22 revealed resident had severe cognitive impairment and was totally dependent on the assistance of one staff with eating. Further review of the MDS assessment revealed Resident #13 required extensive assistance from staff with bed mobility, transfers, dressing, personal hygiene and toilet use. Review of Resident #13's medication administration record (MAR) for March 2022 and April 2022 revealed Resident #13 received 7.5 mg of Mirtazapine for appetite stimulant from 03/06/22 through 04/25/22. Further review of the MAR for March/April 2022 revealed Resident #13 received 15 mg of Mirtazapine at bedtime for appetite stimulant beginning 04/06/22. Review of pharmacy recommendation form for Resident #13 titled, Medical Director's Report, review period 04/01/22 through 04/23/22, revealed a note from the pharmacists to the physician. The note read, Resident has two orders for -Mirtazapine 7.5 mg at bedtime started 03/06/22 -Mirtazapine 15 mg at bedtime started 04/08/22, Please clarify if the Mirtazapine 7.5 mg at bedtime should be discontinued. Interview on 06/07/22 at 11:28 A.M. with the Administrator revealed the facility identified an issue with gradual dose reductions or pharmacy recommendations for the past year has not been given or reviewed by the physician. Interview on 06/08/22 at 1:38 P.M. with the Director of Nursing (DON) confirmed Resident #13 was receiving Mirtazapine 7.5 mg at bedtime and Mirtazapine 15 mg at bedtime. The DON confirmed Resident 365813 Page 12 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0755 Level of Harm - Minimal harm or potential for actual harm #13's family was never notified of the oversight and the physician was never notified of the pharmacy recommendation review. This deficiency substantiates Complaint Number OH00132613. Residents Affected - Some 365813 Page 13 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review and staff interview, the facility failed to timely act on pharmacy recommendations following the monthly Medication Regimen Reviews (MRR's). This affected four (#11, #21, #32, and #13) out of five residents reviewed for MRR's. The facility census was 50. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted on [DATE] with diagnoses that included but were not limited to spinal stenosis of the cervical region, bipolar disorder (depressed, severe with psychotic features), chronic obstructive pulmonary disease, and unspecified anxiety disorder. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not wander, and did not refuse care. Review of the medical record revealed Resident #11 had physician orders for hydroxychloroquine 200 milligrams (mg) by mouth daily, esomeprazole 40 mg by mouth daily, multi-vitamin by mouth once daily, vitamin D 3 1000 units by mouth daily, aspirin 81 mg by mouth daily, Fentanyl 12 micrograms (mcg)/hour patch applied transdermally every 72 hours, fluticasone propionate suspension 50 mcg/actuation two sprays to both nostrils daily, Abilify 20 mg tablet by mouth once daily, gabapentin 100 mg by mouth three times daily, cyanocobalamin 500 mcg by mouth once daily, Ativan one mg by mouth every eight hours, propranolol 10 mg by mouth once daily, trazodone 25 mg by mouth once daily at bedtime, and Prozac 40 mg by mouth once daily. Review of the medical record revealed Resident #11 received monthly Medication Regimen Reviews. On 04/13/22 and 05/13/22 Pharmacist #425 recommended Gradual Dose Reduction for Abilify (aripiprazole) 20 mg taken by mouth once daily. On 05/13/22 Pharmacist #425 noted AIMS test was last completed on 09/2021 and recommended Resident #11 be re-assessed for involuntary movement. There was no documentation which indicated the physician had been notified and no documented response from the physician. Review of the medical record revealed Resident #11 last AIMS assessment occurred on 09/03/2021. Interview on 06/07/22 at 11:09 A.M. the Administrator stated she took over as interim Administrator of the building on 05/09/22. The Administrator audited medical charts last week and discovered monthly pharmacy recommendations had not been addressed for any resident including Resident #11, for the past six months to one year. The Administrator clarified that the pharmacy completed monthly medication reviews but the recommendations were unaddressed because nursing staff did not notify the physician of the recommendations. 3. Record review for Resident #32 revealed an admission date of 11/10/21. Diagnoses included post -traumatic stress disorder, benign prostatic hyperplasia, essential primary hypertension, cerebral infarction due to thrombosis, Coronavirus Disease 2019 (COVID-19), hemiplegia and hemiparesis, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, rheumatoid arthritis, major depressive disorder, dysphagia, and attention deficit hyperactivity disorder. Review of the quarterly MDS assessment, dated 04/13/22, revealed Resident #32 had intact cognition 365813 Page 14 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as evidenced by his brief interview for mental status (BIMS) score of 14. Further review of the MDS assessment revealed Resident #32 required extensive assistance from staff with bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. Resident #32 required supervision from staff with eating. Review of the of the pharmacy recommendation form for Resident #32 titled, Medical Director's Report, review period 11/01/21 through 11/22/21 revealed pharmacy recommendation to review if Atorvastatin, Alendronate, Calcium and Acetaminophen should be restarted? Review of the, Medical Director's Report, review period 01/01/22 through 01/14/22 revealed pharmacy recommendation to please review if Atorvastatin, Alendronate, Calcium and Acetaminophen should be restarted. Review of the Medical Director's Report, review date 05/01/22 through 05/13/22 revealed pharmacy recommendation, Resident was on Atorvastatin prior to admission. Please review and clarify if needs to be restarted. 4. Review of the medical record for Resident #13 revealed an admission date of 03/05/22 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the MDS for Resident #13 dated 03/11/22 revealed resident had severe cognitive impairment and was totally dependent on the assistance of one staff with eating. Further review of the MDS assessment revealed Resident #13 required extensive assistance from staff with bed mobility, transfers, dressing, personal hygiene and toilet use. Review of Resident #13's medication administration record (MAR) for March 2022 and April 2022 revealed Resident #13 received 7.5 mg of Mirtazapine for appetite stimulant from 03/06/22 through 04/25/22. Further review of the MAR for March/April 2022 revealed Resident #13 received 15 mg of Mirtazapine at bedtime for appetite stimulant beginning 04/06/22. Review of pharmacy recommendation form for Resident #13 titled, Medical Director's Report, review period 04/01/22 through 04/23/22, revealed a note from the pharmacists to the physician. The note read, Resident has two orders for -Mirtazapine 7.5 mg at bedtime started 03/06/22 -Mirtazapine 15 mg at bedtime started 04/08/22, Please clarify if the Mirtazapine 7.5 mg at bedtime should be discontinued. Interview on 06/07/22 at 11:28 A.M. with the Administrator revealed the facility identified an issue with gradual dose reductions or pharmacy recommendations for the past year has not been given or reviewed by the physician. Interview on 06/08/22 at 1:38 P.M. with the Director of Nursing (DON) confirmed Resident #13 was receiving Mirtazapine 7.5 mg at bedtime and Mirtazapine 15 mg at bedtime. The DON confirmed Resident #13's family was never notified of the oversight and the physician was never notified of the pharmacy recommendation review. Review of the facility policy titled, Medication Administration, undated, revealed the facility, will implement a medication administration program that incorporates systems with established goals to meet each residents needs as well as our regulatory requirements. 2. Review of the medical record for Resident #21 revealed an admission date of 09/15/20. Diagnoses included chronic obstructive pulmonary disease, hypertension, Alzheimer's disease, hyperlipidemia, anxiety disorder, gastroesophageal reflux disease, dementia, history of falling, psychotic disorder, and major depressive disorder. 365813 Page 15 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS assessment for Resident #21, dated 04/01/22, revealed the resident had an impaired cognition. Resident #21 had a brief interview of mental status (BIMS) score of three. The resident required extensive assistance with hygiene, toileting, dressing, walking in corridor/room, and transfers. Resident #21 required a limited amount of assistance from staff with locomotion on/off the unit. Resident #21 supervision with eating and bed mobility. No hallucination, delusions, or rejection of care were noted on the assessment. Review of the physician orders for Resident #21 in May 2022 revealed orders for Seroquel, Ativan, and Remeron. Review of the history of the Ativan order revealed that Resident #21 had been ordered Ativan 0.5 milligrams three times daily since 11/07/20. Review of the pharmacy recommendation reports for Resident #21 revealed in April and May 2022 the pharmacy recommended a gradual dose reduction for Ativan 0.5 mg three times daily. Interview on 06/07/22 with the Administrator confirmed the MRR for Resident #21 has not been timely addressed by the physician. 365813 Page 16 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 medical record review and staff interview, the facility failed to ensure residents were free from unnecessary psychotropic medications by ensuring there was an end date for as needed (PRN) antianxiety (lorazepam) medication. This affected one (#9) of five residents reviewed for psychotropic medications. The facility census was 51. Findings include: Review of Resident #9 admitted on [DATE] with diagnoses that included but were not limited to Pick's disease, nondisplaced fractures of third and fifth metatarsal bones, unspecified convulsions, type II diabetes, and unspecified dementia. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had severely-impaired cognition, had no behaviors, rejected care one to three days per week, and did not wander. Resident #9 was a two person assist and required extensive assistance for ADL's. Review of care plan dated 05/03/2022 revealed Resident #9 used anti-depressant and anti-anxiety medications related to depression and anxiety. Interventions included administer anti-depressant/anti-anxiety medications as ordered, monitor/document side effects, and monitor for resident safety. Review of the medical record revealed Resident #9 had physician orders for lorazepam 0.5 milligrams (mg) by mouth every six hours as needed for anxiety written on 03/24/22 with no end date. Review of the medical record revealed Resident #9 had Medication Regimen Reviews performed monthly. On 04/13/2022 and 05/13/2022 Pharmacist #425 noted Resident #9 had an order for lorazepam 0.5 mg by mouth every six hours as needed with no stop date. There was no documented response from the physician and the order remained indefinite. Interview on 06/09/2022 at 10:19 A.M. the Administrator verified Resident #9's order for lorazepam dated 03/24/2022 had no stop date. 365813 Page 17 of 19 365813 06/15/2022 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 observation, staff interview, and policy review, the facility failed to ensure hand hygiene was completed during meal services for residents. This affected five (#12, #30, #15, #17 and #9) randomly observed residents observed during meal service. The facility census was 51. Residents Affected - Some Findings include: Observation on 06/06/2022 from 12:06 P.M. to 12:12 P.M. revealed dietary delivered meal cart to 100-Hall. State Tested Nursing Assistant (STNA) #238 delivered a lunch tray to Resident #15 and did not sanitize hands before she retrieved the next tray from food cart. STNA #238 delivered tray to Resident #12, removed lids from dishes, opened the resident's milkshake, and left room without sanitizing her hands. STNA #238 returned to the food cart, retrieved the next tray, and delivered tray to Resident #30, and left the room without sanitizing her hands. Interview on 06/06/2022 at 12:12 P.M. with STNA #238 verified she did not sanitize or wash her hands after she delivered meal trays to Residents #15, #12, and #30. STNA #238 stated she was supposed to sanitize her hands after every tray. Observation on 06/06/2022 from 12:12 P.M. to 12:18 P.M. revealed STNA #228 delivered and set up a lunch tray for Resident #17 and did not wash or sanitize her hands before or after leaving the room. STNA #228 walked to the 200-hall, pulled a tray off the open meal cart, carried it back to the 100-hall, and delivered the tray to Resident #12. STNA #228 removed the lunch tray STNA #238 had delivered to Resident #12 by mistake, setting the old tray on top of a clothing hamper, and set up the new tray for Resident #12. STNA #228 did perform hand hygiene before she left the room. STNA #238 walked to the end of 200-Hall to retrieve open food cart and propelled the cart to 100-Hall. STNA #238 removed a tray from the open cart, delivered it to Resident #9, asked Resident #9 if she was hungry, and sat down to begin feeding Resident #9 without performing hand hygiene. Interview on 06/06/2022 at 12:19 P.M. STNA #228 verified she had not performed hand hygiene between meal tray delivered to Residents #17, #12 and #9 and before starting to assist Resident #9 with the meal. STNA #228 stated she understood was supposed to sanitize hands after every tray and both before and after feeding a resident. Review of policy titled Hand Hygiene dated 08/01/2018 revealed staff performed proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 365813 Page 18 of 19 365813 06/15/2022 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL , review of the staff Coronavirus Disease 2019 (COVID-19) vaccination list/matrix, review of the facility policy and staff interview, the facility failed to implement their vaccination policy and monitor staff members to ensure that 100% (percent) of staff received the COVID-19 vaccine, have a pending request for exemption, or have been identified as appropriate for a temporary delay per Centers for Disease Control (CDC) guidance. The vaccination rate for the facility was calculated at 98.75%. The facility's census was 51. Residents Affected - Few Findings include: Review of the facility staff COVID-19 vaccination matrix revealed the facility had a total of 80 employees. Further review of the COVID-19 vaccination matrix revealed the facility had 40 employees fully vaccinated for COVID-19, 1 employee (Dietary Aide #360) partially vaccinated for COVID-19, and 39 employees who had not received any doses of the COVID-19 vaccination, however, they had a granted non-medical exemption in place. Review of the Verification of National Health Care Safety Network (NHSN) data dated 05/29/22 revealed the facility had 62.5% percentage rate of staff who were fully or partially vaccinated. Review of the facility policy regarding COVID-19 vaccinations titled, COVID-19 Vaccination, dated 01/01/21, revealed the facility follows the guidelines according to CDC and CMS. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice. Interview on 06/09/22 at 10:27 A.M. with the Human Resource Manager (HR) #204 confirmed the hire date for dietary aide (DA) #360 was 03/29/21. HR #204 stated DA#360 told her DA #360 wanted to complete an exemption form but was unable to obtain one. HR #204 stated DA #360 explained to HR #204 that is when decided she would take the COVID-19 vaccine and received her first dose on 08/30/21, however, she failed to complete the second dose. Interview on 06/13/22 at 12:25 P.M. with the Administrator revealed the staff must have the COVID-19 vaccination or a medical/religious wavier in place to work at the facility. The Administrator stated if they do not have this, they are not eligible to work. The Administrator confirmed DA #360 continued to work at the facility without completing an exemption form or completing the second dose of COVID-19. COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). Facility staff vaccination rates under 100% constitute non-compliance under this rule. Within 30 days after issuance of this memorandum, less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule. 365813 Page 19 of 19