Hawthorn Glen Nursing Center

Inspectors wroteBased observation, staff interview, record review, and facility policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all residents. The facility census was 61.

Inspectors wroteBased on interviews and record review, the facility failed to timely initiate and complete Preadmission Screening and Resident Review, (PASRR). This affected four residents (Resident #57, # 74, 35 and #5) of six residents reviewed for preadmission screening. The facility total census was 61. Findings Include: 1. Record review of Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #57 include hypertension, morbid obesity, diabetes, schizophrenia, depressive disorder and anxiety. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required set up assistance with Activity of Daily Living skills. Review of PASRR documentation revealed no documenting of a PASRR screen prior to admission. A Level I PASRR was not completed and signed until 06/23/23. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure medications were dated, labeled, and not expired. This had the potential to affect 36 (Resident #25, Resident #32, Resident #3, Resident #19, Resident #29, Resident #1, Resident #62, Resident #18, Resident #51, Resident #63, Resident #34, Resident #9, Resident #52, Resident #45, Resident #54, Resident #50, Resident #56, Resident #71, Resident #72, Resident #39, Resident #28, Resident #73, Resident #55, Resident #76, Resident #46, Resident #20, Resident #40, Resident #41, Resident #10, Resident #11, Resident #8, Resident #30, Resident #61, Resident #17, Resident #36, and Resident #63) residents. The facility also failed to ensure medications were disposed of properly. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure resident funds were disbursed to the resident's estate within 30 days as required. This affected one (Resident #75) of six residents reviewed for funds. The facility census was 61.

Inspectors wroteBased on resident interview, staff interview, and policy review the facility failed to ensure residents know their Resident Rights. This had the potential to affect 12 (Resident #20, Resident #23, Resident #13, Resident #55, Resident #42, Resident #14, Resident #60, Resident #57, Resident #39, Resident #63, Resident #5, and Resident #77) residents who attend the Resident Council meetings out of 61 residents. The facility census was 61.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to timely complete and submit a Self-Reported Incident (SRI) as required by the Ohio Department of Health, (ODH). This affected one resident (Resident #18) of five residents reviewed for SRI reporting. The facility total census was 61. Findings Include:Record review of Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include breast cancer, depressive disorder, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required moderate assistance for Activity of Daily Living skills. Review of the SRI reported on 04/11/25 to ODH, revealed the incident occurred on 04/11/25, and submitted as completed on 06/05/25. [...]

Inspectors wroteBased on interview, record review , and facility policy review, the facility failed to thoroughly investigate a Self-Reported Incidents (SRI). This affected two residents (Residents #18 and #32) of five residents reviewed for SRI investigations. The facility total census was 61. Findings Include: 1. Record review of Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include breast cancer, depressive disorder, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required moderate assistance for Activity of Daily Living skills. Review of SRI dated 05/05/25 revealed the resident was found to have a bruise of unknown origin on her thumb. Review of staff investigations revealed no written staff statements of the incident. [...]

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure care conferences were completed quarterly for Resident #43. The facility census was 61.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to obtain an order for oxygen therapy. This affected two residents (Resident #25 and Resident #51) out of three reviewed for oxygen therapy. The facility census was 61. Findings Include:1. Review of the medical record for Resident #25, revealed an admission date of 06/27/25. Diagnoses included but were not limited to acute kidney failure, sleep apnea, and asthma. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated revealed a Brief Interview for Mental Status (BIMS) of 15 indicates intact cognition. The resident was assessed to be independent for eating, oral hygiene, toileting, shower/bath independent, partial/moderate assistance dressing, and supervision or touching assistance for personal hygiene.2. Review of the medical record for Resident #51, revealed an admission date of 04/24/25. [...]

Inspectors wroteBased on record review, interview, and policy review the facility failed to provide behavioral health services to one (Resident #2) of three residents reviewed for behavior health. The facility census was 61.

Inspectors wroteBased on observation, interviews and record review , the facility failed to provide social services to maintain the resident's mental health after a traumatic incident. This affected three residents, (Residents # 18, #32 and #38) of five residents reviewed following a traumatic incident. The facility total census was 61. Findings Include: 1. Record review of Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include breast cancer, depressive disorder, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required moderate assistance for Activity of Daily Living skills. Review of Resident #18 State Reported Incident (SRI) dated 04/11/25 revealed the resident alleged a man came into her room and tried to remove her outer wear pants. [...]

Inspectors wroteBased on observation, staff interview, review of planned menu, substitution log, and policy review, the facility failed to follow the menu for residents ordered a puree diet. This affected five (Residents #8, 26, 43, and 55) of five residents ordered a puree diet. The facility also failed to have a dietician sign off on meal substitutions. This had the potential to affect all residents residing in the facility. The facility census was 61. Review of the puree menu for lunch on 07/30/25 revealed beef enchiladas, seasoned black beans, corn, Mexican street cornbread, snickerdoodle cookie, and coffee/tea. Observation on 07/30/25 at 11:13 A.M. revealed puree food being served was enchiladas, corn, black beans, and pie. Interview 07/30/25 at 11:17 A.M. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide a therapeutic diet as ordered by the physician. This affected one resident (Resident # 26) of one resident reviewed for therapeutic diets. The facility total census was 61. Findings Include: Record review of Resident #26 revealed the resident was admitted to the facility on [DATE]. The resident received hospices services. Diagnoses for Resident #26 include hypertension, dementia, obesity, and cancer antigen. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was totally dependent on staff for dressing and hygiene, transfers and eating. The resident received a regular puree nectar thick liquids diet and nutritional supplement three times a day. [...]

Inspectors wroteBased on observations, record review, review of Emergency Medical Services (EMS) report, review of emergency room (ER) records, review of hospital records, staff interviews, review of personnel record, review of job descriptions, and review of facility policy, the facility failed to ensure residents were free from accidents while being transported by the facility's bus. This affected one (#25) of the three residents reviewed for accidents. The facility census was 64.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure fall interventions were implemented to address the root cause of resident's falls. This affected one (#7) of three residents reviewed for falls. The census was 57.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.