Every finding on record at O'Neill Healthcare North Ridgeville

Based on record review, review of incident log, review of witness statements, and staff interviews, the facility failed to properly transfer a resident which caused an injury. This affected one (#69) of the three residents reviewed for transfers. The census was 128.Findings Include: Review of the medical record for Resident #69 revealed an admission date of 07/16/24. Diagnoses included Parkinson's Disease, dementia, muscle weakness and brain stem stroke syndrome.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively impaired. The resident required substantial to maximum assistance for bed-to-chair transfers.Review of weekly skin checks dated 01/08/25 and 01/15/25, revealed no new skin issues identified.Review of the incident log revealed Resident #69 had a skin tear incident on 01/18/25 at 9:15 P.M.Review of a witness statement dated 01/18/25 and authored by former Certified Nursing Assistant (CNA) #700, revealed she used the sit-to-stand on Resident #69 and when they placed the resident on the side of the bed, the resident complained of leg pain. When former CNA #700 looked down, the resident was bleeding and so got the nurse.Review of a witness statement dated 01/18/25 and authored by CNA #750, revealed they went to put Resident #69 in bed and do a check and change. CNA #750 asked CNA #700 for assistance with the sit-to-stand lift. Resident #69 complained of pain in her left leg. CNA #750 lifted the resident's pant leg and saw blood on the resident's pants and there was a cut. She notified the nurse.Review of an undated witness statement by the former Director of Nursing (DON), now Regional Director of Clinical Services (RDCO) #600, revealed Resident #69's husband requested a meeting to review the laceration from 01/18/25. RDCO #600 met with the resident's husband, daughter and son. They reviewed the positioning of the wheelchair, the mechanical (sit-to-stand) lift and the environment with them. They discussed edema to her legs and potential for injury related to the mechanical lift leading to the laceration on the outer aspect of her leg. The resident had reported she felt pressure on her leg during the transfer and when the CNA went to reposition her leg in the bed, there was blood on her hand, and she notified the nurse. After reviewing the incident, it was determined the laceration occurred during the transfer. The resident was changed from a sit-to-stand mechanical lift to a Hoyer mechanical lift to prevent further injury.Review of nurse's progress note recorded as a late entry on 01/19/25 at 5:02 A.M., revealed Resident #69 returned from the emergency room (ER) at 1:45 A.M. with diagnoses of laceration with 14 sutures. The resident's leg was wrapped with non-adherent dressing, kerlix and an ace wrap. The resident also returned with Hibclens cleaning solution and an order for bacitracin ointment (over the county antibiotic ointment). The resident's leg was elevated. There were no correlating progress notes documented about the incident which led to the ER visit and the resident receiving the 14 sutures. Review of a physician order dated 01/19/25 for Resident #69, revealed the resident was ordered to have right lower leg sutures covered with Bacitracin external ointment 500 unit/grams (gm) every shift for laceration/wound for five days and monitor for infection. The order was discontinued 01/24/25. Review of the physician progress note dated 01/19/25 and authored by the Physician #500, revealed Resident #69 was assessed with a laceration on the leg. Physician #500 documented the staff notified him the prior day, but they did not know how the laceration happened. A photograph of the laceration was sent to him, and he thought it needed to be repaired. Resident #69 was sent to the ER where sutures were applied. The resident was assessed with leg swelling; skin was warm and dry with laceration and a wound present.Review of a nurse's progress noted dated 01/20/25 at 5:13 A.M. for Resident #69, revealed the nurse spoke with Resident #69's husband about the incident on 01/18/25 resulting in a laceration to right lower leg, the origin of the laceration, the education that was provided to staff to prevent further injury and the treatment being provided. Review of physician orders dated 01/20/25 for Resident #69, revealed the resident's bed frame was to be padded for safety, Tubi grips (elasticated tubular bandages to help with swelling/edema) were to be in place and wheelchair legs were to be removed prior to transfers. Review of physician orders dated 01/22/25 for Resident #69, revealed the resident was ordered to have the right lower leg cleansed with Hibiclens solution, bacitracin applied to the wound, covered with abdomen (ABD) pad, wrapped with Kerlix daily and monitor for signs and symptoms of infection. The order was discontinued on 02/02/25. Review of the facility's Concern Log dated 01/22/22, revealed Resident #69's family was concerned with the resident's transfer status which resulted in a skin tear. The resolution included therapy evaluating the resident's transfer status and transfer status changed to a Hoyer transfer. The wheelchair leg and bedframe were padded, and nursing staff competency was completed. The comments section on the concern log indicated the family was satisfied with the resolution. Review of a therapy note dated 02/04/25 for Resident #69, revealed the resident was evaluated due to a new onset of decrease in strength, transfers, range of motion, balance, functional activity tolerance, static and dynamic balance and increased need for assistance which placed the resident at risk for falls and further decline in function. The resident sustained a calf laceration on 01/18/25 and required 14 stitches. The stitches were removed on 02/03/25. The resident was consulted to improve strength and balance. The resident was assessed with strength, balance, activity intolerance and functional mobility deficits. The resident was unsteady with weight bearing activities in the stand-up lift, and it was painful. The resident has a decreased quality of life and recommended a Hoyer lift for transfers. Interview via phone on 09/11/25 at 11:56 A.M. with former CNA #750, revealed she transferred Resident #69 to the bed on 01/18/25 when the resident complained of pain. CNA #750 stated she looked at the resident's leg and it was bleeding, so she called for the nurse. CNA #750 stated the blood was dry and thought something happened earlier. She denied resident hitting her leg on anything.Interview via phone on 09/11/25 at 11:59 A.M. with CNA #700, stated she could not remember exactly what happened but stated they used a sit-to stand lift on Resident #69 and was not sure if the resident hit her leg on the bed frame or what happened. CNA #700 stated the blood on Resident #69's leg was still wet. CNA #700 stated the resident did not complain until they picked her legs up and put them on the bed. They told the nurse who immediately came to assess the resident. CNA #700 stated she had to review how to use the sit-to stand with the unit manager.Interview on 09/11/25 at 12:03 P.M. with the DON, revealed RDCO #600 was training her to become the DON at the time of the incident on 01/18/25 involving Resident #69. The DON's understanding was Resident #69 was being transferred via a sit-to-stand mechanical lift, when the resident complained of pain and the CNAs noticed blood on the resident's pants. The physician was consulted and wanted Resident #69 to be sent to the ER. The husband was upset, and the family came into the facility to discuss the incident. Therapy staff looked at the bed and the sit-to-stand mechanical lift after the incident and there was nothing sharp on the bed frame or the sit-to stand lift and thought it could be pressure causing edema to open. The DON stated Resident #69 had edema and the laceration could have been caused by the pressure against the equipment. The facility did training with all staff members on sit-to-stand lifts and the staff started using a Hoyer mechanical lift instead of a sit-to-stand and put pool noodles on the bedrails after the incident. The DON stated they did teach-back competency training with the CNAs and then did audits on other units for residents who used the sit-to-stand and found no issues. Interview on 09/11/25 at 2:11 P.M. with Licensed Practical Nurse (LPN) #220, revealed two CNAs were transferring Resident #69 from her wheelchair to the bed via a sit-to-stand mechanical lift. LPN #220 stated the CNAs took the leg rests off the wheelchair prior to transfer. LPN #220 stated when she assessed the resident the blood was still wet. LPN #220 stated after the resident went to the ER, they determined the resident's leg got scraped along the top of where the leg rest fits onto the wheelchair. LPN #220 did not recall any edema but stated the resident did not have her legs wrapped because that would have prevented the injury. LPN #220 stated she discussed this with RDCO #600 at the time of the incident.Interview on 09/15/25 at 12:32 P.M. with RDCO #600, revealed he investigated the incident involving Resident #69 then met with the family to discuss it. RDCO #600 stated he believed the laceration occurred while Resident #69 was in the sit-to-stand and described it as more of a crushing injury than any issues with edema or swelling.The deficient practice was corrected by 02/22/25 when the facility implemented the following corrective actions: On 01/18/25, the resident was sent to the ER for evaluation and returned with 14 sutures in her right lower leg. On 01/18/25, the facility conducted a comprehensive investigation of the incident causing the laceration to Resident #69. The investigation included collecting witness statements and interviewing staff and facility determined it was caused by an unsafe transfer using a sit-to-stand lift. On 01/19/25, Resident #69's transfer orders were reviewed and changed from a sit-to-stand to a Hoyer mechanical lift. On 01/20/25, Resident #69's bed and wheelchair were inspected for sharp edges. The bed rails were padded for safety, tubi grips on the resident were to be in place and the wheelchair legs were to be removed prior to transfers. On 01/20/25, CNA #700 and CNA #750 were educated on transfer and returned a competency demonstrating on how to properly use a sit-to-stand. On 01/20/25 started education and training all nursing staff on proper usage of the sit-to-stand mechanical lift. On 01/22/25, Resident #69 was assessed by wound nurse On 01/23/25, the facility conducted audits of all residents being transferred by a sit to-stand lift. The audits continued through 04/02/25 and no additional issues were discovered. On 02/04/25, the resident was assessed by the Therapy Department due to new onset of decrease in strength, range of motion, balance, and increased need for assistance which placed the resident at risk for falls and further decline in function. The resident was assessed with strength, balance, activity intolerance and functional mobility deficits. The resident was unsteady with weight bearing activities in the stand-up lift, and it was painful. The resident has a decreased quality of life and recommended a Hoyer lift for all transfers. On 02/22/25, the facility reviewed the incident log, and no current issues were identified with sit-to-stand.This deficiency represents non-compliance investigated under Complaint Number OH001357840.

Based on medical record review, pharmacy recommendation review, and staff interview, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two (#73 and #117) of five residents reviewed for unnecessary medications. The facility census was 133. Findings include: 1. Review of the medical record for Resident #73 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, diabetes mellitus, and generalized anxiety disorder. Review of the pharmacy recommendation dated 04/29/24 revealed Resident #73 was receiving Lantus insulin five units twice daily with blood sugar fluctuating from normal to elevated. Further review revealed the pharmacist recommended a hemoglobin A1C laboratory value be obtained and consider increasing Lantus if appropriate. The physician marked the box on the document that indicated agreement with the recommendation, signed the document, and dated it 05/13/24. Review of Resident #73's medical record revealed no hemoglobin A1c laboratory results were obtained at the time of the review on 09/18/24. Interview on 09/18/24 at 1:12 P.M. and on 09/19/24 at 7:30 A.M. with the Director of Nursing (DON) stated Resident #73 did not always allow laboratory draws, so the facility usually tried to do any additional laboratory draws with other routine laboratory draws. The DON verified he was unable to find the laboratory result or documentation that the physician wanted the hemoglobin A1c to be drawn with the next routine laboratory draw which was today at the time she addressed the recommendation. 2. Review of the medical record for Resident #117 revealed an admitted [DATE]. Diagnoses included major depressive disorder, peripheral vascular disease, and personal history of nicotine dependence. Review of the pharmacy recommendation dated 05/30/24 revealed Resident #117 had an order for a nicotine patch without titration with a recommendation to add a stop date to nicotine 21 milligrams (mg) per day for six weeks total, followed by 14 mg per day for two weeks, then finish with seven (7) mg per day for two weeks. Further review revealed the physician agreed with the recommendation, documented V.O. (verbal order), and signed and dated the form 09/17/24. Review of Resident #117's physician's order for September 2024 revealed active orders dated 09/17/24 for a nicotine transdermal patch 21 mg per 24 hours for seven days with a start date of 09/18/24 and an end date of 09/25/24; a nicotine transdermal patch 14 mg per 24 hours for seven days with a start date of 09/26/24 and an end date of 10/03/24; and a nicotine transdermal patch 7 mg per 24 hours for seven days with a start date of 10/04/24 and an end date of 10/11/24. Interview on 09/18/24 at 1:12 P.M. with the DON verified the pharmacy recommendation for Resident #117 dated 05/30/24 was missed and the titration order was written on 09/17/24. The DON stated it was not related to the pharmacy recommendation; the physician decided to do the titration on her own. The DON stated he did not know about the pharmacy recommendation until today. Review of the policy titled, Medication Regimen Review, dated 10/01/18, revealed for non-urgent recommendations, the facility and attending physician must address the recommendation(s) in a timely manner that meets the needs of the resident but no later than their next routine visit to access the resident and the attending physician should document in the medical record, what irregularity has been reviewed, what actions has been taken to address the issue, and the pharmacy recommendation itself can be used as a tool to document in the medical record, or a notation may be indicated in the medical record/EHR.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place per the plan of care and physician order for Resident #2. This affected one ( Resident #2) of three residents reviewed for falls. The facility census was 125. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included dementia, weakness, difficulty in walking, muscle weakness, dysphagia, anxiety, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. No behaviors were noted. Review of fall risk assessments dated 06/20/22 and 07/02/22 revealed the resident was at high risk for falls. Review of the plan of care dated 06/30/22 revealed the resident was at risk for falls due to history of falls, dementia, unsteadiness, cognitive impairment, and impaired gait and mobility. Interventions included anti-rollback device to wheelchair, alarm to bed to alert staff of unassisted transfers, call light within reach, chair alarm to chair to alert staff of unassisted transfers, low bed, non-skid footwear, dump back to wheelchair, bed against wall, and bed in lowest position. Review of physician orders for June 2022 identified an order dated 06/20/22 for a bed alarm to alert staff of unassisted transfers, check placement and function every shift. Review of the nursing note dated 07/02/22 at 2:30 A.M. revealed Resident #2 was found on the floor during rounds. The resident had no injuries, and the bed alarm was not working when checked. Immediate interventions put into place included keeping items in reach and ensure the bed alarm was placed when the resident was in bed and check to ensure the alarm was connected and working. Review of the fall investigation dated 07/02/22 revealed Resident #2 sustained an unwitnessed fall. The bed alarm was on the bed but was not working when checked. Immediate interventions included keeping items in reach and for the bed alarm to be in place. Review of the nursing note dated 07/11/22 and timed 8:15 P.M. revealed Resident #2's roommate called for help. Resident #2 rolled from the low bed and was found kneeling on the floor, toward his bed. An assessment was completed including vital signs and immediate interventions put into place included alarm to bed and floor mat beside bed. Review of the fall investigation dated 07/11/22 revealed Resident #2 rolled from low bed with no injuries. The resident stated he needed to go to the restroom. Immediate interventions included alarm to bed and floor mat beside bed. The alarm was not on the bed at the time of the fall. Interview on 07/21/22 at 1:34 P.M. with the Director of Nursing (DON) verified the bed alarm for Resident #2 was documented as not working when the resident sustained a fall on 07/02/22. Additionally, the bed alarm was not implemented when the resident sustained a fall on 07/11/22. The DON reported Resident #2 had moved to a new room on 07/11/22 and the bed alarm was not implemented prior to the resident's fall. Review of facility policy titled, Falls Prevention and Management Policy and Procedure, dated January 2013, revealed the purpose of the policy was to identify residents at risk for falls and plan appropriate care and interventions to maintain the resident's safety. This deficiency substantiates Complaint Number OH 117.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents except residents (#12, #15, #37, #104, and #105) who received nothing by mouth. The facility census was 116. Findings include: During the initial tour of the kitchen on 02/14/22 from 9:01 A.M. to 9:21 A.M. with Certified Dietary Manager (CDM) #700 revealed the hood above stove appeared dusty and greasy. The oven to the right of the stove appeared very old with buildup of burnt food and grease inside and along the side with the operating dials and surface that faced the stove. The top of the oven appeared crusted with a hardened blackish dust and grease. The top portion of the steamer appeared crusted with a hardened blackish, dusty grease. The glass panels of the doors were completely covered in a yellowish tannish coating. The beverage cart across from the oven that housed coffee and hot water carafes, had various food debris on the bottom shelf. The reach in cooler had various food on the floor of the cooler. The reach in freezer had a very large ice buildup on floor of the freezer with a bag of sausage stuck in it. Interview on 02/14/22 between 9:01 A.M. to 9:21 A.M. with CDM #700 verified the above findings. Review of the undated facility policy General Sanitation of Kitchen revealed the staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.

Based on medical record reviews, resident and staff interviews, the facility failed to ensure one of six residents (Resident #94) reviewed for medications, did not receive a [CONDITION(S)] drug ([MEDICATION(S)]) without adequate indications for use. The facility census was 116. Findings include: Review of Resident #94's medical record identified admission occurred to the facility on [DATE] following a hospitalization for a fall that occurred at home. Resident #94 was in the hospital from 12/21/21 through 01/04/22. Resident #94 has medical diagnoses that include; post Covid, anxiety, Diabetes and [CONDITION(S)]. Review of the hospital discharge records dated 01/04/22 identified Resident #94 has no previous Psychiatric history. The hospital record identified no evidence as the why Resident #94 was started on the [MEDICATION(S)] (anti-psychotic) medication. The medication records for Resident #94 confirmed she received the [MEDICATION(S)] daily from 01/04/22 through 02/01/22. Review of Physician orders dated 02/01/22 identified an increase in the [MEDICATION(S)] along with a urinalysis to check for a urinary tract infection ([CONDITION(S)]). The record identified the [MEDICATION(S)] was increased to two times a day. The records identified Resident #94 did have a urinary tract infection, which was treated with an antibiotic. The records identified no reason for the use of or increase in [MEDICATION(S)], and or psychiatry issues for the use of the medication. Interview with Resident #94 occurred on 02/16/22 at 8:29 A.M. and Resident #94 identified correctly all the medications she was taking at home prior to admission, which did not include [MEDICATION(S)]. Resident #94 was asked about the [MEDICATION(S)] medication that was started upon discharge from the hospital and she identified she has not idea why she is on the medication. Resident #94 whom is alert and oriented, confirmed she has no issues with her mood and or psychiatry history and no reason to be on that medication. Interview with the facility Director of Nursing on 02/16/22 at 1:50 P.M. confirmed the Certified Nurse Practioner (CNP) changed the order to discontinue the [MEDICATION(S)] medication after discussion today. The interview confirmed the facility could not locate a medical necessity for the use of the [MEDICATION(S)].

Based on record review and interview, the facility failed to ensure eye drop medication was given per physician orders. This affected one resident (#86) of seven residents reviewed for medication. The facility census was 116. Findings include: Review of the medical record for Resident #86 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care of plan for potential for vision impairment related to [CONDITION(S)], blepharitis (eyelid inflammation), and [CONDITION(S)] (drooping) of eyelids. Vision impairment corrected with glasses. Interventions included Instill or apply eye medication as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition and was independent with set up help only for bed mobility, transfers, toilet use, eating, and ambulation. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/11/22 revealed a number 11. No noted indication of what 11 referred to. Review of the progress notes dated 02/03/22 at 8:48 P.M. revealed an orders administration note that did not indicate concerns related to the medication. Review of the progress notes dated 02/11/22 at 9:36 P.M. revealed an orders administration note the [MEDICATION(S)] Solution 0.005 % was on order and not available. Review of the health status note dated 02/12/22 at 6:25 A.M. revealed a late entry note that the physician was notified of the missing eye drop. Order obtained to hold until available. Review of the progress notes dated 02/12/22 at 10:04 P.M., 02/13/22 at 8:49 P.M., and 02/14/22 at 8:36 P.M. revealed orders administration notes for the [MEDICATION(S)] Solution 0.005 % indicating it was on order and not available. Interview on 02/16/22 at 3:22 P.M. and at 4:07 P.M. with the Director of Nursing (DON) revealed on 02/11/22 the eye drops needed to be reordered but wasn't sure what happened on 02/03/22. DON stated she needed to talk with nurse for 02/03/22. DON stated Resident #86 did not receive the eye drops on 02/11/22 through 02/14/22. Follow-up interview on 02/17/22 at 9:48 A.M. with DON stated she talked with the nurse and Resident #86 did not receive the eye drops on 02/03/22. DON stated the nurse stated she couldn't find them.

Based on record review, staff and guardian interview, facility incident investigation documentation, and facility policy, the facility failed to ensure Resident #34 was transported correctly in a tilt-n-space chair and sustained a laceration to the forehead requiring sutures. This affected one (#34) of six residents reviewed for accidents. The facility census was 116. Findings include: Review of the medical record for the Resident #34 revealed an admitted [DATE]. Diagnoses included metabolic [CONDITION(S)], [CONDITION(S)] disease, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the most recent Minimum Data Set (MDS) assessment, revealed the resident had impaired cognition. The resident was total dependence of one staff for locomotion off the unit, and extensive assist of two staff for transfer. Hematoma and laceration noted to forehead. Review of the care plan dated 12/05/22 revealed tilt-n-space chair to be reclined/position while transporting. Review of the progress note 02/8/22 at 7:08 P.M. revealed State tested Nursing Assistant (STNA) #210 approached the nurse's station and asked nurses to identify this resident at that time Registered Nurse (RN) #300 told her the resident's name and to tilt her chair back because she will slide out of the chair. STNA #210 began wheeling resident from the television to her room. Then nurse heard a loud thump and at that time saw resident on the floor face down. Head to toe body check and range of motion (ROM) of all extremities was assessed. Assisted off the floor with assist of three and gait belt. Abrasion noted above the right brow, hematoma and laceration on the forehead. Neurological checks started and medicated with Acetaminophen for pain. Review of the fall investigation worksheet dated 02/08/22 at 7:08 P.M. revealed Resident #34 being transported in upright tilt-n-space chair, Resident #34 leaned forward and fell out of chair. Hematoma and laceration noted to forehead. Resident #34 sent to the emergency room and returned with three sutures to forehead as well as bruising. In Addition, received new orders for routine Acetaminophen 325 (mg) milligrams twice a day and to tilt back tilt-n-space chair while transporting. Interview on 02/14/22 at 3:29 P.M. with the guardian stated agency staff was wheeling Resident #34 to bed and did not tilt back her tilt-n-space wheelchair while transporting her down the hallway and she fell forward out of the chair and sustain a minor laceration. Interview on 02/17/22 at 9:42 A.M. with the Director of Nursing (DON) stated the tilt-n-space chair should of been titled to keep from leaning forward. The DON verified the tilt-n-space chair was not tilted and Resident #34 fell forward out of her chair while being transported. Review of the facility policy titled Falls Prevention and Management Policy and Procedures, dated 01/2013, revealed purpose to identify residents at risk for falls and plan appropriate care and interventions to maintain the residents safety. This deficiency substantiates Complaint Number OH 127.

Based on observation, staff and resident interviews, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore eye protection (goggles or faceshield) while providing resident care during moderate to substantial community transmission of Coronavirus Disease 2019 (COVID-19) to potentially prevent the spread of COVID-19 infections. This had the potential to affect all 84 residents residing in the facility. The facility census was 84. Findings included Observation on 12/02/20 at 2:18 P.M. revealed Registered Nurse (RN) #300 administered medication to Resident #49. RN #300 wore a face mask but had on no eye protection when she administered the medications. Interview on 12/02/20 at 2:20 P.M., RN #300 verified she had no eye protection on while administering medication to Resident #49. Observation on 12/02/20 at 2:32 P.M. revealed Licensed Practical Nurse (LPN) #200 was working at the nurses station. LPN #200 had on a facemask but no eye protection. Interview on 12/02/20 at 2:32 P.M. LPN #200 revealed staff only wear eye protection while providing care to residents in isolation. Interview on 12/02/20 at 2:36 P.M., Resident #45 stated staff wore a facemask when they provided care but no goggles or faceshield. Interview on 12/02/20 at 2:46 P.M., Resident #17 stated staff wore a facemask when they were in his room and sometimes they wore a faceshield. Observation on 12/02/20 at 2:49 P.M. revealed State tested Nursing Assistant (STNA) #100 and STNA #101 were repositioning Resident #18 in his wheelchair. STNA #100 and STNA #101 wore facemask's but no eye protection. Interview on 12/02/20 at 2:50 P.M., STNA #100 and STNA #101 verified they were not wearing eye protection while providing resident care. Observation on 12/02/20 at 2:58 P.M. revealed LPN #201 had on a facemask but no eye protection in the resident hallway. Interview on 12/02/20 at 2:58 P.M., LPN #201 stated eye protection only was wore in the isolation unit. Interview on 12/03/20 at 9:20 A.M., the Director of Nursing (DON) revealed she was unaware of the CDC guidelines for staff to wear eye protection. Interview on 12/03/20 at 2:01 P.M., the Administrator verified the facility had no policy for staff to wear eye protection except while caring for new admissions or working on a COVID-19 unit. Review of the information from the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 11/04/20 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). HCP should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of information from the CDC titled COVID-19 Nursing Home Data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg revealed counties with a low COVID-19 positivity rate would be less than five percent or identified as green; counties with a medium COVID-19 positivity rate would be five to 10% or identified as yellow; and counties with a high COVID-19 positivity rate would be greater than 10% or identified as red. Further review of the information for the week ending 11/18/20 revealed the county where the facility was located had an 11 percent (%) positivity rate or was red; for the week ending 11/25/20 the county positivity rate was 12% and or was red; and for the week ending 12/02/20 the county positivity rate was 12.9% and or was red.

Based on record review and staff interviews, the facility failed to ensure Resident #1's advanced directive was accurately reflected in the electronic medical record. This affected one (#1) of three residents reviewed for advance directives. Findings include: Review of the closed medical record for Resident #1 revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the five-day Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 was cognitively intact and showed no signs of [MEDICAL CONDITION] or behaviors. Review of the physician progress notes [REDACTED].#2, dated [DATE], revealed Resident #1 was admitted from a serious admission from the hospital with extreme volume overload and the initiation of [MEDICAL TREATMENT]. The resident's status was currently still serious, and her prognosis remained serious. Review of the [DATE] physician order [REDACTED]. The order was discontinued on [DATE] at 11:46 P.M. in the electronic medical record. Resident #1 was a do not resuscitate comfort care (DNR-CC) code status starting on [DATE] at 8:40 A.M. in the electronic medical record. Review of the Do Not Resuscitate (DNR) Form indicated Resident #1 was a DNR-CC code status, signed by Physician #2 on [DATE]. The following protocol was effective immediately and providers would not perform cardiopulmonary resuscitation (CPR). Review of the physician's orders [REDACTED].M. written by Registered Nurse (RN) #3, revealed Resident #1 had an absence of vital signs by this nurse and other nurse at 11:06 P.M. and absence of corneal reflexes. Physician #2 called and ordered to release the body. Interview on [DATE] at 10:20 A.M. with the Director of Nursing (DON) revealed Resident #1 had mentioned to Registered Nurse (RN) #3 that she didn't want to be a full code status anymore. RN #3 notified Physician #2 of Resident #1's request and the physician signed the DNR-CC form on [DATE]. The DON verified RN #2 was aware of the change of code status from full code to DNR-CC however, Physician #2 didn't write a telephone order of DNR-CC to alert nursing to change the code status in the electronic medical record. RN #2 was on lunch break when Resident #1 coded so the other nurses in the building started CPR and the paramedics were called and arrived. Once RN #2 came back from lunch and notified the other nurses and paramedics of Resident #1 being a DNR-CC, CPR was stopped. The DON verified the [DATE] physician order [REDACTED].#1 did not match the DNR-CC form signed by Physician #2 dated [DATE]. The DON verified CPR was started on a resident when a code status wasn't known, and CPR was stopped once the DNR form was obtained. Interview on [DATE] at 10:45 A.M. with Regional Registered Nurse (RRN) #4 stated CPR was initiated on a resident when the code status wasn't known. However if a nurse knew a resident was a DNR-CC code status, CPR would not be initiated. This deficiency substantiates Complaint Number OH 130.

Based on medical record review and staff interview, the facility failed to provide written notification to the resident and the resident representative family at the time of transfer to the hospital. This affected two (#47, #285) of three residents reviewed for hospitalization . The facility census was 142. Findings include: 1. Medical record review revealed Resident #47 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a nurse's progress note dated 03/06/19 at 2:53 P.M. revealed Resident #47 was admitted to the hospital for a [MEDICAL CONDITION]. Review of the medical record for Resident #47 revealed no documented evidence of written notification of the transfer to the hospital was provided to the resident and the resident's representative. Interview on 04/24/19 at 7:37 A.M. with the Administrator verified the facility was not providing residents and their representatives written notice of transfer to the hospital. Further interview with the Administrator revealed the facility also had no policy to provide written notice of transfer to the hospital. 2. Medical record review revealed Resident #285 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a nurse's progress note dated 04/22/19 revealed Resident #285 was admitted to the hospital for a blood transfusion. Review of the medical record for Resident #285 revealed no documented evidence of written notification of the transfer to the hospital was provided to the resident and the resident's representative. Interview on 04/24/19 at 7:37 A.M. with the Administrator revealed the facility was not providing residents and their representatives written notice of transfer to the hospital. Further interview with the Administrator revealed the facility also had no policy to provide written notice of transfer to the hospital. Review of the Ohio and Federal Nursing home Residents' Bill of Rights hand book dated 02/01/18 provided to all residents revealed the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing.

Based on medical record review, staff interview and review of facility policy, the facility failed to provide notice of the bed hold policy upon resident discharge to the hospital. This affected three (#47, #135, #285) of three residents reviewed for hospitalization . The facility census was 142. Findings include: 1. Medical record review revealed Resident #47 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a nurse's progress note dated 03/06/19 at 2:53 P.M. revealed Resident #47 was admitted to the hospital for a [MEDICAL CONDITION]. Review of the medical record for Resident #47 revealed no documentation the resident was provided a notice of the bed hold policy at the time of discharge to the hospital. Interview on 04/24/19 at 9:25 A.M. with the Administrator revealed the facility was not providing residents a notice of the bed hold policy at the time of transfer to the hospital. Review of the bed hold policy revealed no guidelines to provide notification of the bed hold policy at the time of transfer to the hospital. Review of the Ohio and Federal Nursing home Residents' Bill of Rights hand book dated 02/01/18 provided to all residents revealed at the time of transfer of a resident for hospitalization the facility must provide the resident and the resident representative written notice which specified the duration the bed-hold policy. 2. Medical record review revealed Resident #285 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a nurse's progress note dated 04/22/19 revealed Resident #285 was admitted to the hospital for a blood transfusion. Review of the medical record for Resident #285 revealed no documentation the resident was provided a notice of the bed hold policy at the time of discharge to the hospital. Interview on 04/24/19 at 9:25 A.M. with the Administrator revealed the facility was not providing residents a notice of the bed hold policy at the time of transfer to the hospital. Review of the bed hold policy revealed no guidelines to provide notification of the bed hold policy at the time of transfer to the hospital. Review of the Ohio and Federal Nursing home Residents' Bill of Rights hand book dated 02/01/18 provided to all residents revealed at the time of transfer of a resident for hospitalization the facility must provide the resident and the resident representative written notice which specified the duration the bed-hold policy. 3. Medical record review revealed Resident #135 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the progress note dated 02/07/19 revealed Resident #135 was admitted to the hospital for a surgical procedure. Review of the medical record for Resident #135 revealed no documentation the resident was provided a notice of the bed hold policy at the time of discharge to the hospital. Interview on 04/24/19 at 9:25 A.M. with the Administrator revealed the facility was not providing residents a notice of the bed hold policy at the time of transfer to the hospital. Review of the bed hold policy revealed no guidelines to provide notification of the bed hold policy at the time of transfer to the hospital. Review of the Ohio and Federal Nursing home Residents' Bill of Rights hand book dated 02/01/18 provided to all residents revealed at the time of transfer of a resident for hospitalization the facility must provide the resident and the resident representative written notice which specified the duration the bed-hold policy.

Based on observation and staff interview, the facility failed to ensure an anchoring device to attempt to prevent accidental trauma, pain or injury from excessive tension or removal of a Foley catheter. This affected one Resident (#69) reviewed for catheter care. The facility identified five residents with catheters. The facility census was 142. Findings include: Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #69's care plan dated 03/06/19 revealed an intervention to include a foley catheter leg strap applied to the thigh to be used at all times, ensure some slack in the catheter tubing to prevent pulling on catheter and alternate legs as needed. Observation on 04/24/19 at 9:01 A.M., of Resident #69's catheter care with License Practical Nurse (LPN) #450 revealed the resident did not have an anchoring device fastened to the leg to prevent injury or trauma. Interview on 04/24/19 at 9:19 A.M., with LPN #500 revealed the resident should always have a leg strap because he was known to pull out his Foley. LPN #500 verified the resident did not have an anchoring device (leg strap) applied to the leg. Review of facility policy titled Catheter Care, Urinary undated, revealed ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion site. Note the catheter tubing should be strapped to the resident's inner thigh.

Based on medical record review and staff interview, the facility failed to ensure ongoing communications occurred between the facility and [MEDICAL TREATMENT]. This affected one resident (#109) of two residents (#109 and #205) reviewed for [MEDICAL TREATMENT]. The facility census was 142. Findings include: Medical record review revealed a most recent admission date of [DATE] for Resident #109. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was moderately impaired. Further review revealed Resident #109 attended [MEDICAL TREATMENT] services three times a week on Monday, Wednesday, and Friday. Review of the [MEDICAL TREATMENT] Communication Forms for Resident #109, from 03/01/19 through 04/22/19, revealed there was no communication between the facility and the [MEDICAL TREATMENT] center on 03/04/19, 03/08/19, 03/27/19, 03/29/19, 04/08/19, 04/10/19, 04/15/19, and 04/22/19. Interview on 04/23/19 at 2:48 P.M., with the Director of Nursing (DON) verified Resident #109 attended [MEDICAL TREATMENT] treatments every Monday, Wednesday, and Friday. The DON revealed staff were to obtain the [MEDICAL TREATMENT] Communication Form from the resident after each treatment. If the resident did not have the form, staff were expected to obtain it from the [MEDICAL TREATMENT] center. The DON verified there was no evidence in the medical record of any communication between the facility and the [MEDICAL TREATMENT] center for Resident #109 on 03/04/19, 03/08/19, 03/27/19, 03/29/19, 04/08/19, 04/10/19, 04/15/19, and 04/22/19. Review of an agreement between the facility and [MEDICAL TREATMENT] center titled, Nursing Home [MEDICAL TREATMENT] Transfer Agreement, dated 06/20/11, revealed the [MEDICAL TREATMENT] center would provide to the facility information on aspects of the management of a designated resident's care related to the provision of [MEDICAL TREATMENT] services. Further review revealed the facility was to ensure all appropriate information accompanied all residents at each transfer for [MEDICAL TREATMENT] treatments. Appropriate information was supposed to include the resident's name, address, date of birth, social security number, name and telephone number of the resident's next of kin, insurance information, appropriate medical records including a history of the resident's illness and any laboratory and/or x-ray findings, treatment's currently provided including medications and any changes in the resident's condition (physical or mental), changes in medications, diet, and/or fluid intake. The facility was also to provide with each visit, any advance directive executed by the resident and any other information that would have facilitated adequate coordination of care.

Based on observations and staff interviews, the facility failed to ensure food was covered when served to residents in their rooms. This affected eight residents (Resident #68, #101, #379, #381, #385, #386, #390, #393). The facility identified 64 residents as receiving meals in their rooms. The facility census was 131. Findings include: Observation on the 100 hall on 03/05/18 beginning at 12:33 P.M., revealed Stated tested Nursing Assistant (STNA) #100 and STNA #101 carried meal trays down the hallway with uncovered food to Resident #101, Resident #379 and Resident #381. During an interview on 03/05/18 at 12:44 P.M., STNA #100 revealed I know dietary and all the food should be covered, dietary does not cover all the food on the tray, the food should be wrapped or have a lid. Observations on 03/07/18 beginning at 12:36 P.M., revealed STNA #101 and STNA #102 carried meal hall trays down the hallway with uncovered food to Resident #393, Resident #68, Resident #390, Resident #386 and Resident #385. Interview on 03/07/18 at 12:44 P.M. with STNA #101 revealed food should be covered when carrying the meal tray to the resident room. Interview on 03/07/18 at 12:46 P.M. with Registered Nurse (RN) #300 revealed food did not need to be covered and staff should move the meal tray cart down the hall as they were serving each room. Interview on 03/07/18 at 1:11 P.M. with Registered Dietician (RD) #400 revealed there was no facility policy regarding uncovered food. Further interview with RD #400 revealed staff should have moved the meal tray cart from room to room as they were serving meals. Continued interview with RD #400 revealed staff should not carry meals trays down the hall with uncovered food.

Based on medical record review, staff interview, and review of facility policy, the facility failed to transmit Minimum Data Set (MDS) assessments within the required timeframe. This affected seven residents (#3, #7, #8, #9, #15, #17, and #18) of 20 residents reviewed for resident assessments. The facility census was 131. Findings include: Medical record review for Resident #3 revealed a quarterly MDS assessment dated [DATE] was completed on 05/09/17 and submitted 05/24/17. The MDS assessment was submitted 15 days after the completion date. Medical record review for Resident #7 revealed a quarterly MDS assessment dated [DATE] was completed on 07/10/17 and submitted on 07/27/17. The MDS assessment was submitted 17 days after the completion date. Medical record review for Resident #8 revealed a quarterly MDS assessment dated [DATE] was completed on 07/12/17 and submitted on 07/27/17. The MDS assessment was submitted 15 days after the completion date. Medical record review for Resident #9 revealed a quarterly MDS assessment dated [DATE] was completed on 07/10/17 and submitted on 07/27/17. The MDS assessment was submitted 17 days after the completion date. Medical record review for Resident #15 revealed a quarterly MDS assessment dated [DATE] was completed on 07/12/17 and submitted on 07/27/17. The MDS assessment was submitted 15 days after the completion date. Medical record review for Resident #17 revealed a quarterly MDS assessment dated [DATE] was completed on 07/12/17 and submitted on 07/27/17. The MDS assessment was submitted 15 days after the completion date. Medical record review for Resident #18 revealed a quarterly MDS assessment dated [DATE] was completed on 07/10/17 and submitted on 07/27/17. The MDS assessment was submitted 15 days after the completion date. Interview on 03/08/18 at 11:49 A.M., Licensed Practical Nurse (LPN) #206 revealed he/she scheduled and completed resident MDS assessments. LPN #206 verified quarterly MDS assessments were required to be submitted no later than 14 days after the completion date. LPN #206 verified Resident #3, #7, #8 #9, #15, #17, and #18's quarterly assessments listed were submitted more than 14 days after the completion date.

Based on staff interview and medical record review, the facility failed to ensure the physician was notified of urine sensitivity results for one (#45) of five residents reviewed for unnecessary medications. The facility census was 131. Findings include: Review of the medical record for Resident #45 revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of a progress note dated 07/15/15 at 11:50 A.M. revealed Resident #45 was sweating and not responding. She was assessed and the physician called. The physician ordered laboratory tests including a urinalysis with culture and sensitivity. Review of the urinalysis and culture, dated 07/17/15, revealed Resident #45 had over 100,000 colonies of Escherichia coli. Review of a progress note dated 07/17/15 revealed the physician was notified. The physician ordered the antibiotic,[MEDICATION NAME] milligrams (mg) twice daily for five days for the urinary tract infection. Review of the urine culture and sensitivity dated 07/18/15, revealed the organism was resistant to Cipro. Review of Resident #45's progress notes revealed the physician was not notified of the urine sensitivity results and the organism was resistant to the antibiotic ordered. Review of the Medication Administration Record [REDACTED]. Interview on 09/10/15 at 12:31 P.M., Licensed Practical Nurse #8 confirmed the urine culture and sensitivity indicated the infecting organism was resistant to Cipro. After review Resident #45's progress notes, she confirmed the physician was not notified of the results of the urine sensitivity.

Based on observation, medical record review, and staff interview, the facility failed to accurately assess a pressure ulcer to the coccyx of one (Resident #173) of two residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The facility census was 131. Findings include: Medical record review for Resident#173 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Nursing Data Collection skin assessment, dated 04/18/15, revealed the resident exhibited moisture associated skin damage (MASD) at the area of the bifurcation of the buttocks. Review of the admission history and physical, dated 05/11/15, revealed the resident exhibited some [MEDICAL CONDITION] of lower extremities, moist groin areas, and had some perianal skin excoriation. Review of the most recent comprehensive quarterly Minimum Data Set (MDS) assessment, dated 07/20/15, revealed the resident had MASD and no pressure ulcers had developed since admission. Review of facility Weekly Wound Documentation from 04/19/15 through 09/08/15 revealed the resident was admitted with and continued with MASD to the right buttock, specifically the bifurcation of the buttocks over the coccyx. The Weekly Wound Documentation, dated 07/21/15 at 4:00 P.M., documented the resident's coccyx to measure 0.5 centimeters (cm) by 0.5 cm by 0.2 cm deep, identified a deterioration of the wound condition, and a wound consult was initiated. Review of a Wound Visit Report, dated 07/21/15, by Wound Certified Nurse Practitioner (WCNP) #10 revealed the resident developed a coccyx pressure ulcer on 07/20/15. Review of progress notes from Wound Physician #11 dated 07/31/15, 08/28/15 and 09/04/15, documented the coccyx pressure ulcer was debrided to remove necrotic tissue on each of the dates. Each note indicated the resident was non-compliant with laying down in bed, wanted to be in recliner. A wound care observation for Resident #173 was conducted on 09/10/15 at 10:45 A.M. with Licensed Practical Nurse (LPN) #9. The observation noted a pressure ulcer over the coccyx area inside the bifurcation of the buttocks. The wound measured approximately 0.5 cm by 0.4 cm by 0.3 cm deep. Interview at the time of the observation with LPN #9 confirmed the open area had full thickness skin loss with subcutaneous tissue observed and was located over the bony coccyx area. Interview on 09/10/15 at 11:15 A.M., LPN #8 stated she rounded with Wound Physician #11 each week and also completed the facility Weekly Wound Documentation. LPN #8 confirmed when the consultant wound service visited on 07/21/15, the wound consultant documentation revealed a pressure ulcer had developed on 07/20/15 in the area where MASD had been present for several months. LPN #8 confirmed weekly facility wound documentation through 09/08/15 continued to document the presence of MASD to the resident's coccyx and did not identify the pressure area that developed on 07/21/15.

Based on observation and interview, the facility failed to provide a dignified dining experience for the residents on the West wing. This affected 12 ( Resident #37, Resident #60, Resident #67, Resident #104, Resident #108, Resident #141, Resident #156, Resident #159, Resident #166, Resident #168, Resident #201,and Resident # 215) of 37 residents residing on the West Wing who eat in the West Wing dining room. The facility census was 136. Findings Include: 1. The lunch service was observed in the West Unit dining room on 06/09/14 from 12:20 P.M. until 12:58 P.M. 12 residents ( Resident #37, Resident #60, Resident #67, Resident #104, Resident #108, Resident #141, Resident #156, Resident #159, Resident #166, Resident #168, Resident #201,and Resident # 215) were present in the dining room. State tested nursing assistants (STNA) #2, STNA #3, and licensed practical nurse (LPN) #1 were present in the dining room and proceeded to deliver the meals. After delivery of the meals, LPN #1 left the dining room. Resident #108, who had [DIAGNOSES REDACTED]. Her annual minimum data set (MDS) assessment completed on 04/18/14 indicated she needed limited assistance of one for dining. Resident #108's meal consisted of mashed potatoes and gravy, green beans, and an open faced roast beef sandwich with gravy which was given to her at 12:20 P.M. The food was placed on the tray table and she began to feed herself. Resident #108 attempted to eat the roast beef sandwich but it had not been cut up for her. At 12:29 P.M. STNA #2, who was feeding Resident #156, left Resident #156 and stood over Resident #108 to cut up the resident's roast beef sandwich. STNA #2 then continued to stand and feed Resident #108. Resident #156 attempted to feed herself but was not successful in getting any food to her mouth. Resident #156's quarterly MDS completed on 04/05/14 indicated for dining the resident was an extensive assist of one person. From 12:29 P.M. to 12:45 no staff were present to feed Resident #156. At 12:45 STNA #3 sat down to feed Resident #156. At 12:51 P.M. STNA #3 stopped feeding Resident #156 and went to sit next to Resident #60. At 12:37 P.M. STNA #2 stopped feeding Resident #108 and went to sit beside Resident #168 and feed her. At 12:42 P.M. STNA #2 stopped feeding Resident #168 and went over to Resident #108 and started feeding her, again standing over the resident. At 12:52 STNA #2 stopped feeding Resident #108 and returned to finish feeding Resident #168. Eating at the same table as Resident #168 were Resident #201 and Resident #141 whom STNA #2 encouraged to eat their meals while walking between Resident #108 and Resident #168. 2. A second observation of the lunch service in the West Wing dining room was conducted on 06/10/14 from 12:19 P.M. until 1:15 P.M. The trays arrived and were given to the residents at 12:20 P.M. Nine residents were present in the dining room. Registered Nurse (RN) #6, STNA #2 and STNA #4, delivered the trays to the residents. At 12:47 P.M. Resident #215 said the lunch she had been eating was not her lunch as the slip had another resident's name on it. STNA #2 was the only staff member in the dining room at the time and did not respond to Resident #215's statement. At 12:59 P.M. STNA #4 brought Resident #215's correct tray to her. At 12:53 P.M. STNA #2 was called out of the dining room by LPN #1 leaving no staff in the dining room. At 1:06 P.M. STNA #2 was observed standing over Resident #60 holding a glass of milk for the resident to drink. Resident #67 was noted to sleep through lunch. The resident ate approximately 25% of lunch. No assistance was offered to Resident #67. STNA #2 woke the resident at 1:11 P.M. and escorted her out of the dining room. An interview with the Director of Nursing (DON) on 06/12/14 at 12:00 P.M. verified staff had been trained to sit next to the residents when feeding them, converse with the residents, and not talk to each other during meals. The DON also confirmed the staff should not be called away while feeding the residents.

Based on surveyor observations, medical record review and staff interview, it was determined that the facility failed to provide adequate supervision for one cognitively impaired resident (#200) with verbal and physical behaviors to ensure other residents were provided with a safe environment. This resulted in actual harm for Resident #182 who was pushed to the floor by Resident #200 which resulted in a fractured left forearm. This affected one (#182) of four residents reviewed for accidents and supervision. The total facility census was 135. Findings include: 1. Review of Resident #182's medical record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The assessment also noted the resident exhibited a behavior of wandering daily. Resident #182 currently resides on the secured dementia unit. Review of Resident #182's nurses' notes revealed an entry dated 08/13/10 at 8:50 P.M. that indicated the resident was standing in front of the nurses' station when Resident #200 came from behind her and pushed her with both hands. Resident #182 fell on to her left side but did not hit her head. The physician was contacted and a stat x-ray of the left wrist was ordered which revealed a transverse fracture of the distal radius (a forearm fracture). Resident #182 was sent to the emergency room for treatment. On 08/31/10 at 2:30 P.M. and 4:15 P.M. and on 09/01/10 at 8:03 A.M., 9:33 A.M., 1:40 P.M. and 4:20 P.M., Resident #182 was observed ambulating throughout the dementia unit with her left arm in a cast supported with a sling. 2. Review of Resident #200's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] indicated the resident had short and long term memory problems, had moderately impaired cognitive skills for daily decision making and his mental function varied over the course of the day. The assessment also noted the resident exhibited daily behaviors of wandering, being verbally abusive, socially inappropriate and disruptive and also resistive to care. Resident #200 resided on the secured dementia unit. On 06/09/10, Resident #200 was sent to the emergency room for geriatric psychiatric services due to being physically abusive and verbally threatening towards facility staff. The resident pushed one staff into the wall and grabbed another staff member by the wrist. The resident was demonstrating agitation and confusion and was difficult to redirect. He was readmitted to the facility on [DATE]. The re-admission orders [REDACTED]. Review of a" Physician Visit Form" dated 07/03/10 revealed the primary care physician saw Resident #200 and noted he was unsure what the psychiatric hospital had done for the resident for the past three weeks. The physician indicated the resident still had significant dementia with combativeness, behavior disturbances and agitation and sometimes resisted his daily care. The physician's plan directed the resident's behavior needs to be checked and monitored closely. Review of Resident #200's plan of care for mood and behaviors, initiated on 05/01/10, indicated the resident can become very anxious/angry without warning and his mood and behaviors are not easily altered. It noted that diversional activity and coaxing are usually effective but short term. The care plan included a goal that the resident would not harm self or others. Some of the listed interventions included; allow ample time for expression of feelings/fears and offer encouragement and reassurance and reorientation as needed. The care plan included no interventions regarding supervision, such as increasing supervision when the resident displayed increased agitation or restlessness. Review of nurses' from 07/12/10 at 7:05 P.M. revealed Resident #200 pushed another resident in a wheelchair down the hallway very fast. The other resident was screaming for the resident to slow down and stop. The nurse intervened and removed Resident #200 from the other resident. The nurse documented Resident #200 balled up his fist at the nurse as if he was going to hit her. Resident #200 was redirected again by staff to take a walk. Review of the resident's care plan revealed no changes in interventions were attempted. The care plan did not address how they would provide supervision and closely monitor the resident's behaviors to prevent further resident-to-resident altercations. On 07/14/10 at 12:35 A.M. a nurse note entry indicated a new order for Ativan 0.5 milligrams (mg) was ordered to be given every night at bedtime. Review of nurses' notes dated 07/30/10 at 9:40 P.M. revealed Resident #200 displayed increased pacing and restlessness. Resident #200 grabbed another resident's arm and was speaking to him angrily. Resident #200 was redirected, given reading materials which was short term effective. The nurse noted the resident was medicated with Ativan earlier due to escalation of behaviors. Review of the resident's care plan revealed no changes in interventions were attempted. The care plan did not address how they would provide supervision and closely monitor the resident's behaviors to prevent further resident-to-resident altercations. Review of nurses' notes dated 08/04/10 at 6:00 P.M. revealed Resident #200 was verbally abusive towards another resident and shook his fist at the resident. The nurse noted redirection was unsuccessful and Ativan was given for increased agitation. Review of the resident's care plan revealed no changes in interventions were attempted. The care plan did not address how they would provide supervision and closely monitor the resident's behaviors to prevent further resident-to-resident altercations. Review of nurses' notes dated 08/05/20 at 7:40 P.M. revealed the resident became aggressive towards another resident. Resident #200 pulled his fist back and was talking angrily to the other resident. The residents were separated and redirected. The nurse documented Resident #200 was pacing and restless and difficult to redirect. The interventions utilized had a short term effect so the resident was medicated with Ativan for his behaviors. Review of the resident's care plan revealed no changes in interventions were attempted. The care plan did not address how they would provide supervision and closely monitor the resident's behaviors to prevent further resident-to-resident altercations. Review of nurses' notes dated 08/08/10 at 10:00 P.M. revealed Resident #200 became verbally aggressive with other residents. The nurse noted that redirection was semi-successful. Review of the resident's care plan revealed no changes in interventions were attempted. The care plan did not address how they would provide supervision and closely monitor the resident's behaviors to prevent further resident-to-resident altercations. On 08/11/10 at 2:15 P.M. a nurse note entry indicated Resident #200 had been ambulating since 7:00 A.M. with different interventions attempted. The resident was wandering in and out of other resident rooms requiring constant redirection. The resident was also urinating beside his bed and in the hallway in between toileting. The primary care physician visited the resident and was updated on his behaviors. The note indicated an intramuscular injection of Ativan was administered to the resident. At 3:50 P.M., the nurse documented the resident was attempting to pull down his pants in the hallway. At 5:35 P.M., the resident pulled down his trousers to urinate in the hallway. At 8:00 P.M., the resident was wandering in and out of other resident rooms picking up belongings of the other residents. The nurse indicated the 7:00 P.M. Ativan that was administered with little to no results. Nurses' notes dated 08/12/10 at 12:00 A.M. indicated Resident #200 was medicated with Ativan for increased aggressive behaviors (not listed) with unsuccessful redirection. The nurse also documented the resident continues to go into female rooms and shoved another resident when redirection attempted. The nurse wrote she will continue to monitor. At 2:00 A.M. revealed Resident #200 continued to wander and mumble verbal threats. The nurse documented she would continue to monitor. At 8:30 A.M., the psychiatrist was updated on the resident's behavior and ordered an increase in the resident's Risperdal (antipsychotic medication). Review of the resident's care plan revealed no changes in interventions were attempted. The care plan did not address how they would provide supervision and closely monitor the resident's behaviors to prevent further resident-to-resident altercations. Review of nurses' notes dated 08/13/10 at 8:10 P.M. revealed Resident #200 walked toward the nurses' station around 6:30 P.M. Resident #182 was standing in the middle of the hall. Resident #200 walked towards Resident #182 and pushed in the back with both of his hands causing Resident #182 to fall and injure herself. Resident #200 was removed and placed on 1:1 supervision. The nurse documented a call was placed to the physician and Resident #200 was sent to the geriatric psychiatric hospital for evaluation. Interview with the Director of Nursing on 09/01/10 at 1:52 P.M. revealed the facility was aware of Resident #200's behaviors. She stated staff were to redirect when he had increased behaviors. On 09/01/10 at 3:30 P.M., Licensed Practical Nurse (LPN) #46, the unit manager where Resident #200 resided, was interviewed. She stated that when the resident presented with increased behaviors the physician was notified and his medications were adjusted. LPN #41 verified Resident #200's care plan contained no interventions to address increased supervision and monitoring of the resident when he presented with increased behaviors. She further verified the resident freely wandered the dementia unit most of the day and night. Interview with State tested Nurse Aide (STNA) #31 on 09/01/10 at 4:15 P.M. verified Resident #200 was free to roam the dementia unit without staff assistance. The STNA stated there were no specific timeframe for checking on Resident #200's whereabouts. STNA #31 indicated the only residents who require scheduled visual checks by staff are the residents identified at risk for elopement.