Health inspection·May 24, 2023

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 medical record review, observation, and staff interview, the facility failed to ensure fall prevention interventions were in place. This affected one (#20) of three residents reviewed falls. The facility census was 60. Findings included: Medical record review for Resident #20 revealed an admission date of 09/19/21. Diagnoses include dementia with behaviors, atrial fibrillation, depression, hypotension, intraabdominal pelvis mass, elevated cancer antigens, Alzheimer's disease with early onset, hypertension, myocardial infarction, fibromyalgia, insomnia, retention of urine, restless and agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 revealed had severe cognitive impairment. Resident #20 required extensive assistance from two staff members for bed mobility, transfers, and toileting. Resident #20 was incontinent of bladder and bowel. Resident #20 had two or more falls without injury since the last MDS. Review of the plan of care for Resident #20 dated 04/16/21 with revisions on 05/19/23 revealed the resident is at risk of injury due to: behavior of putting self on the floor in room to sit related to poor cognition. Interventions include consider pain, discomfort, hunger, boredom, and personal needs that the resident is unable to communicate as possible causes of behavior, anticipate and meet needs to attempt to control behavior problems, encourage activities and socialization, provide calm reassurance, redirection or distractions and assess effectiveness and provide positive reinforcement for appropriate behavior. Reveal of the plan of care for Resident #20 dated 04/16/21 with revisions on 05/01/2023 revealed the resident is at risk for fall's and fall related injury. Interventions include assess fall potential on admit, quarterly, and change of condition, assist with and monitor positioning when in bed and chair, assure safe, proper body alignment, assist with toileting needs and incontinence care on routine rounds, resident request, bed put on lowest position, ensure dycem in chair at all times, scoop mattress at all times, involve resident and/or responsible party in treatment plan, update as needed regarding change in condition, keep call light within reach, encourage use, and answer calls promptly, keep fluids and frequently used items within easy reach, bed in lowest position while occupied, and proper footwear. Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Page 1 of 4 365813 365813 05/24/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of the physician orders for Resident #20 revealed an order dated 11/28/23 for ensure dycem to chair at all times, and an order dated 03/05/22 for fall mats to side of bed for fall prevention. Observation on 05/22/23 at 2:45 P.M. of Resident #20 being transferred to bed with State Tested Nursing Assistant (STNA) #66 and #38. Observation of Geri-recliner seat revealed no dycem was in place. Residents Affected - Few Interview on 05/22/23 at 2:50 P.M. with STNA #66 and #38 verified dycem was not present as it should have been. Further stated they would have to find a piece of dycem and put it in her chair. Observation on 05/23/23 at 5:29 A.M. of Resident #20 resting in bed revealed no fall mat in place beside bed as ordered. Interview on 05/23/23 at 5:31 A.M. with Licensed Practical Nurse (LPN) #62 verified fall mat was not in place and should have been per Resident #20's physicians' order. Interview on 05/23/23 at 2:45 P.M. with Director of Nursing (DON) stated fall mat and dycem for Resident #20 are orders from the physician and included on the plan of care. Interventions should have been in place as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00142678. 365813 Page 2 of 4 365813 05/24/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, the facility failed to provide a resident with appropriate urinary incontinent care. This affected one (#20) of three residents reviewed for urinary incontinence care. The facility census was 60. Findings include: Medical record review for Resident #20 revealed an admission date of 09/19/21. Diagnoses include dementia with behaviors, atrial fibrillation, depression, hypotension, intraabdominal pelvis mass, elevated cancer antigens, Alzheimer's disease with early onset, hypertension, myocardial infarction, fibromyalgia, insomnia, retention of urine, restless and agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 revealed the resident had severe cognitive impairment. Resident #20 required extensive assistance from two staff members for bed mobility, transfers, and toileting. Resident #20 was extensive assist for eating. Resident #20 was incontinent of bladder and bowel. Review of the plan of care dated 05/12/23 revealed the resident was incontinent of bladder due to dementia, behaviors, and Alzheimer's disease. Interventions include checking resident every two hours and as needed, observe for pattern of incontinence, provide pericare after incontinent episodes. Observation on 05/22/23 at 2:55 P.M. of Resident #20 revealed State Tested Nursing Assistant (STNA) #66 gathered supplies for incontinent care and laid two washcloths on the bedside table without utilizing a barrier or cleaning the table off. STNA #66 and #38 assisted Resident #20 from Geri-chair into her bed without concerns. STNA #66 donned plastic gloves and removed Resident #20's outer clothing and then removed incontinent brief. STNA #38 assisted Resident #20 into position for perineal care. STNA #66 removed gloves and preformed hand hygiene, donning clean gloves. STNA #66 proceeded to pick up washcloths prepared prior to the Hoyer lift transfer (eleven minutes had passed) and cleansed residents perineal area. Resident #20 became agitated and began hitting and pinching both STNA's. STNA #66 completed perineal care using a different area of the washcloth for each swipe of the area, front to back. Resident #20 continued to be combative with staff. STNA #66 then tossed the washcloth into the trash bin next to the bed and picked up the second washcloth laying on the bedside table that was prepared prior to the transfer of Resident #20 into bed. STNA #66 wiped Resident #20' s perineal area using a clean area with each swipe. Resident #20's aggression and combativeness increased, swinging at both STNA's, grabbing and pinching arms. Perineal care was completed, and Resident #20 was redressed with incontinent brief and pants before leaving the room and disposing of the trash. Interview on 05/22/23 at 3:17 P.M. with STNA #66 verified she did not use a basin for Resident #20's incontinence care because the resident did not have one in her bathroom. Further verified she did not have a barrier on the bedside table or cleaned the area before placing supplies on the surface. STNA #66 verified she should have had a towel or plastic bag to contain washcloths. STNA #66 verified the washcloths were cool to the touch and stated she should have transferred the resident and then gathered the washcloths to ensure they were warm. Interview on 05/22/23 at 4:45 P.M. with the Director of Nursing (DON) verified STNA should have used basin to ensure warm water was used for perineal care and further verified the STNA should have 365813 Page 3 of 4 365813 05/24/2023 Hawthorn Glen Nursing Center 5414 Hankins Road Middletown, OH 45044

F 0690 Level of Harm - Minimal harm or potential for actual harm used a barrier on the bedside table to maintain infection control practices. The DON stated it was the expectation that staff use a water basin at the bedside for perineal care to provide washcloths at appropriate and comfortable temperature; however, the facility does not have a policy regarding this expectation. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00142678. 365813 Page 4 of 4