Health inspection·April 11, 2023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure residents received timely and appropriate feeding assistance and supervision with meals. This affected two (Residents #39 and #46) of nine residents reviewed. The census was 53. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #39 admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, unspecified anxiety disorder, and unspecified bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severely impaired cognition, required extensive two-person staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and required extensive one-person staff assistance with eating and locomotion. 2. Review of the medical record revealed Resident #46 admitted to the facility on [DATE] and had diagnoses that included but were not limited to non-traumatic brain dysfunction, unspecified Alzheimer's disease, and unspecified anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #46 had severely impaired cognition, required extensive two-person assistance with bed mobility, transfers, dressing, toileting, locomotion, and personal hygiene, and required limited (staff provide guided maneuvering of limbs) one-person assistance with eating. Review of an undated list of residents who required feeding assistance provided by the facility revealed the facility identified Residents #54, #46, and #38 needed supervision and setup assistance. In addition to setup, Resident #37 needed cueing assistance, and Resident #55 needed feeding assistance. No other residents on the [NAME] Unit were identified on the list. During an interview on 04/10/2023 at 11:05 A.M., STNA #128 stated one (#46) resident on [NAME] Unit needed feeding assistance and two (#39 and #55) residents needed cueing assistance for eating. Observation on 04/10/2023 11:19 A.M. revealed State Tested Nurse Aide (STNA) #128 set up trays for residents, directed Resident #55 to sit, and began feeding Resident #55 at 11:35 A.M. The lunch meal consisted of lasagna, steamed broccoli, a breadstick, and a dessert of diced peaches, ice cream, or both. Resident #39 began feeding herself diced peaches with her fingers, and Resident #46 began feeding himself broccoli with his fingers. Page 1 of 8 365813 365813 04/11/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/10/23 at 11:37 A.M. revealed Resident #39 had no food remaining on her plate or tray, and approximately half of the portions of broccoli, lasagna, and peaches were scattered across the resident's lap and floor surrounding her wheelchair. During an interview on 04/10/23 at 11:37 A.M., STNA #128 stated when she finished feeding Resident #55, she would go to the hallway to get Resident #38 out of bed and bring her to the dining room for lunch before assisting Residents #39 and #46 with eating. STNA #128 stated she often had to leave the residents unsupervised in the dining room to attend to other residents on the hall. Observation on 04/10/23 at 11:47 A.M., STNA #128 continued feeding Resident #55 while Resident #39 struggled to remove the lid of her water cup and Resident #46 fed himself a breadstick and attempted to eat ice cream. From 11:57 A.M. to 12:05 P.M., STNA #128 fed Resident #46 a few bites of lasagna, broccoli, and peaches. During an interview on 04/10/23 at 12:14 P.M., STNA #128 verified she provided set-up assistance only to Resident #39 and it appeared that half of her food ended up in her lap or on the floor. STNA #128 verified over 30 minutes had passed between the time she had set up Resident #46's meal tray and the time she sat down and provided feeding assistance to Resident #46. During an interview on 04/11/23 at 8:39 A.M., STNA #266 stated she worked alone on the [NAME] Unit up to four days per week. STNA #266 stated she did not feel it was safe for the residents or the caregiver to have only one aide on the unit and she had expressed these concerns to management, and the concerns were not addressed. STNA #266 stated there was no extra supervision provided during mealtimes, and stated she often had to leave residents unsupervised on the unit to get help with care. Observation on 04/11/23 from 11:27 A.M. to 12:03 P.M., STNA #266 was the only staff providing feeding assistance to residents for lunch on [NAME] Unit. Registered Nurse (RN) #164 was on the hall with the medication cart around the corner from the dining room and was unable to see residents eating while passing medications to residents in their rooms from 11:27 A.M. to 11:45 A.M. STNA #266 set up trays for Residents #37, #39, and #46 who were already seated at tables in the dining room. At 11:49 A.M., STNA#266 obtained gloves and sat down to assist Resident #46 to eat his fish sandwich. Resident #39 tore off pieces of the fish patty and bun and fed herself with her fingers. Resident #39 threw the top of the bun on the floor and attempted eating cake with her hands. At 11:57 A.M., Resident #39 pushed Resident #43's water cup off the table into Resident #43's lap. STNA#266 propelled Resident #39 away from the table and cleaned up the water while Resident #39 clapped repeatedly, grit her teeth, pulled at the miniature blinds, and shook Resident #37's table. STNA #266 offered Resident #39 a sip of water and Resident #39 refused. STNA #266 began cleaning tables and returning trays to meal cart. Resident #39 had consumed approximately half of her fish sandwich and potato chips, one fourth of her cake slice, and none of her soup and crackers or milk. The dining room floor was scattered with bits of cake, potato chips, and remnants of Resident #39's fish sandwich. At 12:02 P.M., STNA #266 redirected Resident #46 from attempting to eat his napkin and began to sit and feed Resident #46 cake. At 12:03 P.M., Resident #39 began pulling at the miniature blinds, continued manic clapping, wringing hands, taking deep breaths, and making repetitive statements. STNA #266 propelled Resident #39 in her wheelchair to the lounge area and finished clearing lunch trays from the dining room. This deficiency represents non-compliance investigated under Complaint Number OH 00141362. 365813 Page 2 of 8 365813 04/11/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, and policy review, the facility failed to ensure residents received timely assistance with toileting and incontinence care. This affected four (#43, #44, #45, and #54) of nine residents reviewed for toileting assistance. The census was 53. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 08/10/22. Diagnoses included but were not limited to unspecified cerebral infarction, unspecified anxiety disorder, and unspecified dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severely impaired cognition. Resident #43 was always incontinent of bowel and bladder and required extensive two-person assistance with toileting. Review of a care plan dated 08/23/22 revealed Resident #43 had an activities of daily living (ADL) self-care deficit and required staff intervention to complete ADLs related to dementia and a simple pelvic fracture. Interventions included but were not limited to assisting with meal intake, assisting with toileting needs, incontinence care on routine rounds and as needed, and use two caregivers as needed to provide safe care. Review of a care plan revealed Resident #43 was incontinent of bowel and bladder related to dementia and decreased awareness of urge. Interventions included but were not limited to assisting with toileting needs and incontinence care on routine rounds and as needed, assist as needed with toileting hygiene, and assist with using incontinence undergarments to maintain social continence. 2. Review of the medical record revealed Resident #44 revealed an admission date of 07/14/21 and had diagnoses that included but were not limited to unspecified dementia with behaviors, unspecified major depressive disorder, and hypothyroidism. Review of the MDS assessments dated 01/12/23 revealed Resident #44 had severely impaired cognition, was occasionally incontinent of bladder, was frequently incontinent of bowel, and required extensive one-person assistance with toileting. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified Alzheimer's disease, diabetes mellitus type II, and stage three chronic kidney disease. Review of the MDS assessment dated [DATE] revealed Resident #45 had severely impaired cognition, was always incontinence of bladder, was occasionally incontinent of bowel, and required extensive one-person assistance with toileting. 4. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, mild protein-calorie malnutrition, and unspecified anxiety disorder. 365813 Page 3 of 8 365813 04/11/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the MDS assessment dated [DATE] revealed Resident #54 had severely impaired cognition, was occasionally incontinent of bowel and bladder, and required one-person supervision with toileting. Observation on 04/10/23 from 11:05 A.M. to 3:13 P.M., revealed State Tested Nurse Aide (STNA) #128 did not provide toileting assistance, incontinence care, or check four (#43, #44, #45, and #54) of nine residents observed on the [NAME] Unit for incontinence and toileting assistance. Observation on 04/10/23 from 12:24 P.M. to 12:47 P.M., revealed STNA #128 laid Resident #44 down in bed without checking for incontinence or offering to toilet, but toileted Resident #55, assisted her to bed, and provided toileting and dressing assistance to Resident #39. Observation on 04/10/23 at 12:51 P.M., revealed the Director of Nursing (DON) entered the [NAME] Unit and propelled Resident #46 away for the unit door. Resident #46 stated to the DON he needed to go to the bathroom. At 12:55 P.M., Licensed Practical Nurse (LPN) #208 and STNA #128 propelled Resident #46 into the bathroom while the DON left the unit in search of a gait belt. At 12:57 P.M., the DON returned with a gait belt and left the room while LPN #208 and STNA #128 toileted Resident #46 who was incontinent of bowel and had stool stuck to his buttocks. LPN #208 left the bathroom to get towels and washcloths and returned at 1:03 P.M. to finish providing incontinence care. Observation on 04/10/23 from 2:16 P.M. to 2:44 P.M., revealed Resident Care Assistant (RCA) #130 supervised the [NAME] Unit while STNA #128 ambulated Resident #38 to the shower room on [NAME] Unit and provided a shower. During an interview on 04/10/23 at 2:44 P.M., RCA #130 verified she did not provide any toileting assistance or check any residents for incontinence while she supervised the unit from 2:16 P.M. to 2:44 P.M. because she was unlicensed. During an interview on 04/10/23 at 2:53 P.M., STNA #128 stated rounds to check residents for incontinence were to be completed every two hours. STNA #128 stated it took longer than two hours to complete a round with the residents sometimes because some of the residents fought staff. STNA #28 verified she had not checked for incontinence or offered toileting to Residents #43, #44, #45, and #54 since 11:00 A.M. Review of policy titled, Care of Incontinent Resident Policy and Procedure, revised 01/20, revealed all residents who were identified as being incontinent had incontinent care provided every two hours with a half-hour leeway to rounds. 365813 Page 4 of 8 365813 04/11/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to provide sufficient staffing to ensure residents received timely assistance with toileting, incontinence care, feeding assistance, and supervision with meals. This affected four (#43, #44, #45, and #54) of nine residents reviewed for toileting assistance and two (Residents #39 and #46) of nine residents reviewed for feeding assistance. The census was 53. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 08/10/22. Diagnoses included but were not limited to unspecified cerebral infarction, unspecified anxiety disorder, and unspecified dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severely impaired cognition. Resident #43 was always incontinent of bowel and bladder and required extensive two-person assistance with toileting. Review of a care plan dated 08/23/22 revealed Resident #43 had an activities of daily living (ADL) self-care deficit and required staff intervention to complete ADLs related to dementia and a simple pelvic fracture. Interventions included but were not limited to assisting with meal intake, assisting with toileting needs, incontinence care on routine rounds and as needed, and use two caregivers as needed to provide safe care. Review of a care plan revealed Resident #43 was incontinent of bowel and bladder related to dementia and decreased awareness of urge. Interventions included but were not limited to assisting with toileting needs and incontinence care on routine rounds and as needed, assist as needed with toileting hygiene, and assist with using incontinence undergarments to maintain social continence. 2. Review of the medical record revealed Resident #44 revealed an admission date of 07/14/21 and had diagnoses that included but were not limited to unspecified dementia with behaviors, unspecified major depressive disorder, and hypothyroidism. Review of the MDS assessments dated 01/12/23 revealed Resident #44 had severely impaired cognition, was occasionally incontinent of bladder, was frequently incontinent of bowel, and required extensive one-person assistance with toileting. 3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified Alzheimer's disease, diabetes mellitus type II, and stage three chronic kidney disease. Review of the MDS assessment dated [DATE] revealed Resident #45 had severely impaired cognition, was always incontinence of bladder, was occasionally incontinent of bowel, and required extensive one-person assistance with toileting. 4. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, mild protein-calorie 365813 Page 5 of 8 365813 04/11/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0725 malnutrition, and unspecified anxiety disorder. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment dated [DATE] revealed Resident #54 had severely impaired cognition, was occasionally incontinent of bowel and bladder, and required one-person supervision with toileting. Residents Affected - Some Observation on 04/10/23 from 11:05 A.M. to 3:13 P.M., revealed State Tested Nurse Aide (STNA) #128 did not provide toileting assistance, incontinence care, or check four (#43, #44, #45, and #54) of nine residents observed on the [NAME] Unit for incontinence and toileting assistance. Observation on 04/10/23 from 12:24 P.M. to 12:47 P.M., revealed STNA #128 laid Resident #44 down in bed without checking for incontinence or offering to toilet, but toileted Resident #55, assisted her to bed, and provided toileting and dressing assistance to Resident #39. Observation on 04/10/23 at 12:51 P.M., revealed the Director of Nursing (DON) entered the [NAME] Unit and propelled Resident #46 away for the unit door. Resident #46 stated to the DON he needed to go to the bathroom. At 12:55 P.M., Licensed Practical Nurse (LPN) #208 and STNA #128 propelled Resident #46 into the bathroom while the DON left the unit in search of a gait belt. At 12:57 P.M., the DON returned with a gait belt and left the room while LPN #208 and STNA #128 toileted Resident #46 who was incontinent of bowel and had stool stuck to his buttocks. LPN #208 left the bathroom to get towels and washcloths and returned at 1:03 P.M. to finish providing incontinence care. During an interview on 04/10/23 at 2:05 P.M., STNA #128 stated she had completed incontinence rounds before 11:00 A.M. and had toileted all the residents except two (#44 and #54) who could toilet themselves. STNA #128 stated she usually completed a round after lunch, but she needed assistance with Resident #43 because she fought and would try to bite staff. Observation on 04/10/23 from 2:16 P.M. to 2:44 P.M., revealed Resident Care Assistant (RCA) #130 supervised the [NAME] Unit while STNA #128 ambulated Resident #38 to the shower room on [NAME] Unit and provided a shower. During an interview on 04/10/23 at 2:44 P.M., RCA #130 verified she did not provide any toileting assistance or check any residents for incontinence while she supervised the unit from 2:16 P.M. to 2:44 P.M. because she was unlicensed. During an interview on 04/10/23 at 2:53 P.M., STNA #128 stated rounds to check residents for incontinence were to be completed every two hours. STNA #128 stated it took longer than two hours to complete a round with the residents sometimes because some of the residents fought staff and one staff member could not do it all. STNA #28 verified she had not checked for incontinence or offered toileting to Residents #43, #44, #45, and #54 since 11:00 A.M. Review of policy titled, Care of Incontinent Resident Policy and Procedure, revised 01/20, revealed all residents who were identified as being incontinent had incontinent care provided every two hours with a half-hour leeway to rounds. 5. Review of the medical record revealed Resident #39 admitted to the facility on [DATE] and had diagnoses that included but were not limited to unspecified dementia, unspecified anxiety disorder, and unspecified bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severely 365813 Page 6 of 8 365813 04/11/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impaired cognition, required extensive two-person staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and required extensive one-person staff assistance with eating and locomotion. 6. Review of the medical record revealed Resident #46 admitted to the facility on [DATE] and had diagnoses that included but were not limited to non-traumatic brain dysfunction, unspecified Alzheimer's disease, and unspecified anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #46 had severely impaired cognition, required extensive two-person assistance with bed mobility, transfers, dressing, toileting, locomotion, and personal hygiene, and required limited (staff provide guided maneuvering of limbs) one-person assistance with eating. Review of an undated list of residents who required feeding assistance provided by the facility revealed the facility identified Residents #54, #46, and #38 needed supervision and setup assistance. In addition to setup, Resident #37 needed cueing assistance, and Resident #55 needed feeding assistance. No other residents on the [NAME] Unit were identified on the list. During an interview on 04/10/2023 at 11:05 A.M., STNA #128 stated one (#46) resident on [NAME] Unit needed feeding assistance and two (#39 and #55) residents needed cueing assistance for eating. Observation on 04/10/2023 11:19 A.M. revealed State Tested Nurse Aide (STNA) #128 set up trays for residents, directed Resident #55 to sit, and began feeding Resident #55 at 11:35 A.M. The lunch meal consisted of lasagna, steamed broccoli, a breadstick, and a dessert of diced peaches, ice cream, or both. Resident #39 began feeding herself diced peaches with her fingers, and Resident #46 began feeding himself broccoli with his fingers. Observation on 04/10/23 at 11:37 A.M. revealed Resident #39 had no food remaining on her plate or tray, and approximately half of the portions of broccoli, lasagna, and peaches were scattered across the resident's lap and floor surrounding her wheelchair. During an interview on 04/10/23 at 11:37 A.M., STNA #128 stated when she finished feeding Resident #55, she would go to the hallway to get Resident #38 out of bed and bring her to the dining room for lunch before assisting Residents #39 and #46 with eating. STNA #128 stated she often had to leave the residents unsupervised in the dining room to attend to other residents on the hall. Observation on 04/10/23 at 11:47 A.M., STNA #128 continued feeding Resident #55 while Resident #39 struggled to remove the lid of her water cup and Resident #46 fed himself a breadstick and attempted to eat ice cream. From 11:57 A.M. to 12:05 P.M., STNA #128 fed Resident #46 a few bites of lasagna, broccoli, and peaches. During an interview on 04/10/23 at 12:14 P.M., STNA #128 verified she provided set-up assistance only to Resident #39 and it appeared that half of her food ended up in her lap or on the floor. STNA #128 verified over 30 minutes had passed between the time she had set up Resident #46's meal tray and the time she sat down and provided feeding assistance to Resident #46. During an interview on 04/10/23 at 3:23 P.M. Licensed Practical Nurse (LPN) #208 stated the [NAME] Unit was always staffed with one nurse aide, and it was difficult to get staff coverage for breaks. LPN #208 stated incontinence and toileting rounds were to be completed every two hours. LPN #208 365813 Page 7 of 8 365813 04/11/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the nurse was responsible for supervising lunch, and verified she did not go back on the unit on 04/10/23 while residents were eating. LPN #208 verified she had not provided any assistance with toileting or incontinence checks while STNA #128 was off the unit. During an interview on 04/11/23 at 8:39 A.M., STNA #266 stated she worked alone on the [NAME] Unit up to four days per week. STNA #266 stated she did not feel it was safe for the residents or the caregiver to have only one aide on the unit and she had expressed these concerns to management, and the concerns were not addressed. STNA #266 stated there was no extra supervision provided during mealtimes, and stated she often had to leave residents unsupervised on the unit to get help with care. Observation on 04/11/23 from 11:27 A.M. to 12:03 P.M., STNA #266 was the only staff providing feeding assistance to residents for lunch on [NAME] Unit. Registered Nurse (RN) #164 was on the hall with the medication cart around the corner from the dining room and was unable to see residents eating while passing medications to residents in their rooms from 11:27 A.M. to 11:45 A.M. STNA #266 set up trays for Residents #37, #39, and #46 who were already seated at tables in the dining room. At 11:49 A.M., STNA#266 obtained gloves and sat down to assist Resident #46 to eat his fish sandwich. Resident #39 tore off pieces of the fish patty and bun and fed herself with her fingers. Resident #39 threw the top of the bun on the floor and attempted eating cake with her hands. At 11:57 A.M., Resident #39 pushed Resident #43's water cup off the table into Resident #43's lap. STNA#266 propelled Resident #39 away from the table and cleaned up the water while Resident #39 clapped repeatedly, grit her teeth, pulled at the miniature blinds, and shook Resident #37's table. STNA #266 offered Resident #39 a sip of water and Resident #39 refused. STNA #266 began cleaning tables and returning trays to meal cart. Resident #39 had consumed approximately half of her fish sandwich and potato chips, one fourth of her cake slice, and none of her soup and crackers or milk. The dining room floor was scattered with bits of cake, potato chips, and remnants of Resident #39's fish sandwich. At 12:02 P.M., STNA #266 redirected Resident #46 from attempting to eat his napkin and began to sit and feed Resident #46 cake. At 12:03 P.M., Resident #39 began pulling at the miniature blinds, continued manic clapping, wringing hands, taking deep breaths, and making repetitive statements. STNA #266 propelled Resident #39 in her wheelchair to the lounge area and finished clearing lunch trays from the dining room. Interview on 04/11/23 at a random time with RN #164 stated on some days staffing was not enough. RN #164 stated she went to the [NAME] Unit to administer medications at lunch time but did not stay to supervise residents during the meal. During an interview on 04/11/23 at 3:20 P.M. the Director of Nursing (DON) stated there was only one nurse aide staffed on the [NAME] Unit per shift since the acuity on the unit was not as high as it used to be. The DON verified there were a couple of unidentified residents that required two-staff assistance with care, and stated the nurse aide could use her cellular telephone to call for help. The DON verified there was no additional staff person assigned to supervise residents on the [NAME] Unit during lunch. This deficiency represents non-compliance investigated under Complaint Number OH00141362. 365813 Page 8 of 8