Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hawthorn Glen Nursing Center during CMS and state inspections, most recent first.
Surveyors found multiple food items in a nourishment room refrigerator that were unlabeled, undated, expired, or visibly spoiled, including fruit, cheese, bologna, and milk. The DON confirmed that these items were not stored according to facility policy, which requires labeling and timely disposal of food.
The facility did not timely initiate or complete required PASRR screenings and hospice condition change submissions for several residents with mental disorders, intellectual disabilities, or significant cognitive impairments. PASRR documentation was missing or delayed for residents with diagnoses such as schizophrenia, dementia, and those receiving hospice care, as confirmed by staff interviews and record reviews.
Surveyors found that medications, including insulin and vaccines, were not consistently dated, labeled, or checked for expiration, and that some vaccines were improperly disposed of in a lidless trash can. These lapses were confirmed by nursing staff and affected multiple residents, in violation of facility policy.
A resident with severe cognitive impairment and multiple medical conditions was discharged, but the facility did not transfer the resident's personal funds to the estate within the required 30-day period. The account remained open for nearly three months after discharge, contrary to facility policy.
The facility did not review Resident Rights during Resident Council meetings for several months, as confirmed by resident and staff interviews and review of meeting minutes. Multiple residents who attended these meetings were unaware of where to find information about their rights, and the omission was attributed to a change in agenda forms by the Activities Director.
A facility did not complete and submit a required Self-Reported Incident (SRI) investigation to ODH within the mandated five working days after an incident involving a resident with multiple diagnoses. The final report and police notification were both delayed, contrary to facility policy.
The facility did not conduct thorough investigations into alleged abuse and injuries of unknown origin for two residents, as required by policy. In both cases, documentation was missing key elements such as staff and resident interviews and non-verbal skin assessments, despite the residents having significant medical histories and cognitive abilities. The Administrator and DON confirmed the lack of proper investigation documentation.
A resident with major depressive disorder, PTSD, and anxiety disorder, who was cognitively intact, did not receive ongoing psychiatric evaluation and treatment as ordered. The last psychiatric service was provided several months prior, despite a current physician order, and this lapse was confirmed by the DON. Facility policy requires individualized behavioral health care, which was not provided in this instance.
Following traumatic incidents such as alleged abuse, unexplained bruising, and theft, three residents with intact cognition and various medical conditions did not receive counseling or psychosocial support. Social service notes lacked documentation of follow-up, and interviews confirmed that no staff checked on the residents' mental health needs after the events.
A resident with severe cognitive impairment and multiple diagnoses did not receive a physician-ordered nectar thick liquids and puree diet. Instead, the resident was fed regular thin milk by a family member without staff supervision, contrary to the care plan. The resident exhibited a slight cough after consuming the thin milk, and staff confirmed that the milk was not thickened as required.
A resident with cognitive impairment and multiple medical conditions had only one care conference completed during their stay, despite facility policy requiring routine care conferences. This was confirmed by record review and DON interview.
Two residents with respiratory and other medical conditions were observed receiving oxygen therapy without physician orders, contrary to facility policy. Both residents confirmed ongoing oxygen use since admission, and the DON acknowledged the lack of required orders during the survey.
Staff did not follow the planned menu for several residents on a puree diet, serving different items than listed and making substitutions without required review or approval from the RD. Multiple menu changes over several weeks were not signed off by the dietician, contrary to facility policy.
A resident with multiple medical conditions fell from her wheelchair during transport due to improper securing, as the facility staff lacked training in transportation safety. The incident occurred when the bus driver had to abruptly stop, causing the resident to fall. The resident was later hospitalized for hypotension related to cardiovascular disease.
A facility failed to implement effective fall interventions for a resident with a history of falls. The resident, with conditions such as stroke and dementia, required assistance for daily activities but was independent in bed mobility. Despite a care plan to review past falls, the facility did not address the resident's repeated attempts to self-toilet, leading to multiple unwitnessed falls. Interventions like non-skid socks and re-education on call light use did not address the root cause, as confirmed by the ADON.
Improper Food Storage and Labeling in Facility Refrigerator
Penalty
Summary
Surveyors observed that food items in the nourishment room refrigerator were not stored in accordance with professional standards or facility policy. Specifically, six packages of fruit, a container of cheese, and a Styrofoam takeout container with unidentified food were found unlabeled and undated. Additional items in the bottom drawer, including two packages of raspberries (dated over a month prior), a package of cheese, and a package of bologna, were covered in a grey, fuzzy substance. The cheese and bologna were undated. Five cartons of milk stored in the refrigerator door were found to be expired. The Director of Nursing confirmed these findings and acknowledged that the food was improperly labeled, undated, expired, and in some cases visibly spoiled. Facility policy requires that food brought in by visitors or family be labeled with the resident's name and date, and that dietary staff monitor and discard items after three days, which was not followed in these instances.
Failure to Timely Complete PASRR Screenings and Submissions
Penalty
Summary
The facility failed to timely initiate and complete Preadmission Screening and Resident Review (PASRR) processes for residents with mental disorders or intellectual disabilities. Specifically, four residents were affected by these deficiencies. One resident was admitted with diagnoses including schizophrenia, depressive disorder, and anxiety, but did not have a PASRR screen completed prior to admission; the Level I PASRR was not completed and signed until several months after admission, and a Level II PASRR was only initiated following a later diagnosis change. Three other residents, all of whom had significant cognitive impairments and were receiving hospice services, did not have required PASRR hospice condition change submissions and results documented in their records. Interviews with the Social Service Designee confirmed that PASRR screenings were either missing, incomplete, or not completed in a timely manner for these residents. The designee acknowledged that diagnosis changes, hospice status, and other significant condition changes should be submitted within a few days, and that newly admitted residents should have PASRRs completed prior to or within 30 days of admission. The findings were based on both record reviews and staff interviews, which verified the lack of timely and complete PASRR documentation for the affected residents.
Failure to Properly Label, Date, and Dispose of Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were properly dated, labeled, and not expired, as required by professional standards. During observations, multiple instances were found where insulin vials for two residents were undated, and a medication cart contained both undated and expired Lantus insulin for two other residents. Additionally, the medication storage room contained intravenous (IV) tubing bags and vaccine vials with only month and year dating, and not all items were properly labeled. These findings were confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged the presence of undated and expired medications. The facility also failed to dispose of medications appropriately. Observations revealed that flu vaccine vials were discarded in a lidless trash can next to the medication cart, which was confirmed by an LPN to be an inappropriate disposal method. The same LPN subsequently removed the vaccines from the trash can and disposed of them correctly. The facility's own medication administration policy requires expiration dates to be checked and open dates to be placed on multi-dose vials, but these procedures were not consistently followed, affecting a significant number of residents.
Delay in Disbursement of Resident Funds After Discharge
Penalty
Summary
The facility failed to disburse a resident's personal funds to the resident's estate within the required 30-day period following discharge, as mandated by facility policy. A review of records showed that a resident with diagnoses including congestive heart failure, hypertension, and dementia, who was severely cognitively impaired, was discharged from the facility. The resident's responsible party had previously authorized the management of personal funds. Despite this, the resident's account, which had a balance of $35.12, was not closed and the funds were not conveyed to the estate until nearly three months after discharge. This delay was confirmed by the facility administrator during an interview and was not in accordance with the facility's written policy on managing personal funds.
Failure to Review Resident Rights During Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their Resident Rights, as required by policy. Review of Resident Council meeting minutes over an 11-month period showed that Resident Rights were not discussed during these meetings. Interviews with several residents confirmed that they were not aware of where to find information about their rights and that these rights had not been reviewed during Resident Council sessions. The Activities Director acknowledged that Resident Rights were omitted from the meetings due to a change in the agenda forms. Facility policy indicated that Resident Rights should be reviewed during Resident Council meetings, but this was not done, affecting multiple residents who attended these meetings.
Failure to Timely Complete and Submit Self-Reported Incident
Penalty
Summary
The facility failed to timely complete and submit a Self-Reported Incident (SRI) to the Ohio Department of Health (ODH) as required. A resident with diagnoses including breast cancer, depressive disorder, and dysphagia, who had intact cognition and required moderate assistance with activities of daily living, was involved in an incident that was discovered and initially reported to ODH on the same day. However, the final investigation report was not completed and submitted to ODH within the required five working days, but instead was submitted nearly two months later. Additionally, the police were not notified at the time of the investigation, but only after the delay was discovered. Facility policy required that the investigation be completed and submitted to ODH within five working days of discovery, which was not followed in this case.
Failure to Thoroughly Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate self-reported incidents (SRIs) involving two residents. For one resident with diagnoses including breast cancer, depressive disorder, and dysphagia, there were two separate SRIs: one involving a bruise of unknown origin on the thumb and another where the resident alleged a staff member held down her hand. In both cases, the investigation lacked written staff statements, resident interviews, and non-verbal resident skin assessments. The only documentation included was an undated staff education sign-in sheet with no presenter or topic listed. For another resident with metabolic encephalopathy, repeated falls, sepsis, COPD, and hypertension, an SRI was filed after a family representative reported bruises of unknown origin on the resident's torso. The investigation documentation for this incident also lacked written staff and resident interviews, as well as non-verbal resident skin assessments. The Administrator and DON confirmed that the investigations did not show documented evidence of a thorough investigation as required by facility policy, which mandates interviews with residents, witnesses, and staff, as well as assessments when injuries of unknown source are reported.
Failure to Provide Required Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to one resident with diagnoses of major depressive disorder, post-traumatic stress disorder, and anxiety disorder. The resident was cognitively intact and had a physician's order for psychiatric evaluation and treatment. Although the resident had been receiving psychiatric services for these conditions, the last documented service was provided on 05/07/24, despite a current order for ongoing evaluation and treatment. The Director of Nursing confirmed that no further psychiatric services had been provided since that date. Facility policy requires individualized care to support residents' physical, functional, and psychosocial needs, but this was not followed in this case.
Failure to Provide Psychosocial Support After Traumatic Incidents
Penalty
Summary
The facility failed to provide necessary social services to support the mental health and psychosocial well-being of residents following traumatic incidents. Three residents with varying diagnoses, including depressive disorder, metabolic encephalopathy, and anxiety disorders, experienced incidents such as alleged abuse, unexplained bruising, and theft of personal property. Despite these events, there was no documentation of counseling or follow-up psychosocial services in the social service notes for any of the affected residents during the periods following the incidents. Interviews with the residents confirmed that none had been visited by staff or offered counseling services after their respective incidents, and each expressed ongoing distress or feelings of violation. The Social Service Designee acknowledged that residents should be assessed and offered psychosocial support after such occurrences, but verified that no such visits or assessments had taken place. Facility policy required notification of the social service department after incidents to ensure psychosocial needs were addressed, but this procedure was not followed for the residents involved.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including hypertension, dementia, obesity, and cancer, did not receive a therapeutic diet as ordered by the physician. The resident, who was severely cognitively impaired and totally dependent on staff for eating, had a physician order for a nectar thick liquids and puree diet, with thin liquids and pleasure foods allowed only under staff supervision. Despite these orders, observations on two separate occasions revealed that the resident's family representative fed the resident regular milk from the original carton using a straw, which was not thickened to nectar consistency. The resident exhibited a slight cough after consuming the thin milk, and there was no staff present to supervise or assist with feeding during these meals. Interviews confirmed that the milk provided was not thickened and that fluids from the kitchen were typically thickened into serving glasses, not left in original cartons. The family representative acknowledged feeding the resident thin milk and noted the resident's cough. The registered dietitian verified that the resident should have received nectar thickened milk unless thin liquids were given under staff supervision, which was not the case during the observed incidents. The facility was unable to provide a policy regarding therapeutic diets and fluid consistencies.
Failure to Complete Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly for a resident with multiple diagnoses, including dysphagia, chronic obstructive pulmonary disease, major depressive disorder, and seizures. The resident, who was cognitively impaired, had only one care conference documented since admission, despite facility policy requiring care conferences to be scheduled after admission, routinely, and with any change in condition. This was confirmed through record review and an interview with the DON, who verified that only one care conference had been completed for the resident during their stay.
Oxygen Therapy Administered Without Physician Orders
Penalty
Summary
The facility failed to obtain physician orders for oxygen therapy for two residents who were receiving oxygen. Both residents had been admitted with medical conditions that included acute kidney failure, sleep apnea, asthma, acute respiratory failure, chronic obstructive pulmonary disease, and sepsis. Medical record reviews showed that both residents had intact cognition and varying levels of independence in daily activities. Despite this, both were observed to be on 2 liters of oxygen via nasal cannula. Further review revealed that neither resident was listed on the facility's oxygen tubing list, and interviews with both residents confirmed they had been receiving oxygen since admission. The DON confirmed that the residents were receiving oxygen without a physician's order, which was not in accordance with the facility's policy that requires a physician's order for oxygen administration except in emergencies. The deficiency was identified during a complaint investigation.
Failure to Follow Puree Diet Menu and Obtain Dietician Approval for Substitutions
Penalty
Summary
The facility failed to follow the planned menu for residents prescribed a puree diet, as observed during meal service and confirmed through staff interviews and document review. Specifically, five residents on a puree diet were served enchiladas, corn, black beans, and pie, instead of the scheduled menu items which included Mexican street cornbread and a snickerdoodle cookie. The Dietary Director confirmed that the cornbread was not prepared for puree diets and that pie was substituted for the cookie. Review of the substitution log revealed that multiple menu substitutions had occurred over a two-month period without the required sign-off from the registered dietician. The registered dietician confirmed she had not reviewed or signed off on these substitutions. Facility policies required that menu changes be evaluated by the dietician and that residents' nutritional needs be met through well-balanced diets.
Resident Safety Compromised During Transport
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in an accident. The resident, who had multiple medical conditions including major depressive disorder, stroke, dementia, and heart failure, was being transported back to the facility from a medical appointment. During the journey, the driver had to abruptly stop the bus to avoid a collision, causing the resident to fall from her wheelchair onto the floor of the bus. It was later discovered that while the wheelchair was secured to the bus, the resident was not secured in the wheelchair with the vehicle's seat belt. The incident was compounded by the lack of proper training for the staff involved in the transportation. The Maintenance Supervisor, who was driving the bus, and the Certified Nurse Assistant accompanying the resident, both admitted to not having received training on how to properly secure residents in the transport vehicle. This lack of training and oversight led to the resident being improperly secured, which directly contributed to the fall. Following the fall, the resident was assessed by facility staff and found to have no immediate visible injuries, but later became unresponsive and was sent to the hospital. The hospital diagnosed the resident with hypotension related to cardiovascular disease, and she was admitted for further treatment. The facility's failure to ensure proper safety measures during transportation and the lack of staff training were significant factors in the occurrence of this incident.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement effective fall interventions for a resident with a history of falls, which was identified during a review of medical records, staff interviews, and policy review. The resident, who had diagnoses including stroke, aphasia, non-Alzheimer's dementia, hemiplegia, and seizure disorder, was admitted to the facility and was rarely or never understood. The resident required assistance for eating, toileting, and transfers but was independent in bed mobility. Despite having a care plan intervention to review past falls and determine their root cause, the facility did not adequately address the resident's repeated attempts to self-toilet, which led to multiple falls. The resident experienced several unwitnessed falls, including incidents where they attempted to self-toilet without assistance, resulting in falls in the bathroom and their room. The interventions implemented, such as encouraging the resident to change positions slowly, wearing non-skid socks, and re-educating the resident on using the call light, did not address the root cause of the falls. The Assistant Director of Nursing confirmed that the interventions did not effectively prevent the resident from attempting to self-toilet, which was the primary cause of the falls. The facility's policy on fall prevention was not effectively applied, leading to this deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Middletown Llc | 2.7 mi | ★★★★★ | 2 | 0 |
| Ohio Living Mount Pleasant | 3.8 mi | ★★★★★ | 3 | 0 |
| Gateway Springs Health Campus | 4.1 mi | ★★★★★ | 0 | 0 |
| Liberty Station Health Campus | 4.4 mi | — | 0 | 0 |
| Doverwood Village | 4.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.