**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit and choosing to remain in the facility. This affected two residents (#222 and #223) of three residents review of appropriate beneficiary notices. The facility census was 80. Findings include: 1. Resident #222 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic kidney disease, and dementia. Further review of the medical record revealed Resident #222 was discharged from skilled services while using her Medicare Part A benefit on 09/29/23 and chose to remain in the facility. Review of the notices given to Resident #222 revealed Resident #222 was given a notice of Medicare non-coverage (NOMNC) as required; however, the additional required skilled nursing advanced beneficiary notice (SNFABN) was not given to Resident #222. 2. Resident #223 was admitted to the facility 05/19/23 with diagnoses including dementia, mood disorder, and delirium. Review of the medical revealed Resident #223 was discharged from skilled services on 07/10/23 and chose to remain in the facility. Review of the notices given to Resident #223 revealed Resident #223 was given a NOMNC as required; however, the additional required SNFABN was not given to Resident #223. Interview with the Administrator on 01/02/24 at 4:15 P.M. verified no SNFABN was given to Residents #222 and #223 as required. Review of the undated facility policy titled The [NAME] Home NOMNC-ABN Procedure revealed In the event the patient is covered under traditional Medicare part A and stays at the facility after the last covered day social services will issue an ABN.

Based on interview, review of facility abuse policy and record review the facility failed to report timely to the Administrator/designee or the State Survey Agency after Resident #37 alleged she was physically and sexually abused on 03/23/21. This affected one resident (Resident #37) out of one resident reviewed for abuse. This had the potential to affect all 64 residents residing in the facility. Findings included: Review of medical record for Resident #37 revealed an admission date of 10/21/20 and diagnoses included Alzheimer's Disease, delusional disorder, dementia with behavioral disturbances, and anxiety disorder. Review of care plan for Resident #37 dated 03/01/21 revealed she had the potential to demonstrate verbally inappropriate behaviors related to mental and emotional illness. She had a history of false accusations towards caregivers. Interventions included analyze key times, places, circumstances, triggers, and what escalated her behaviors and document, and psychological consult as indicated. Review of Medicare five-day Minimum Data Set (MDS) 3.0 dated 03/03/21 revealed Resident #37 had impaired cognition and she had delusions. Review of nursing note dated 03/23/21 at 12:40 A.M. and authored per Licensed Practical Nurse (LPN) #40 revealed Resident #37 came to the nursing desk and stated, I need to talk to you in my room please. LPN #40 revealed she went into Resident #37's room and Resident #37 started to cry and whimper and pulled up her shirt showing LPN #40 her right breast. Resident #37 stated A man came in here and smashed my boob down and now its flat and hanging down low, and he also fingered my down there (vagina) as she whispered the word vagina. LPN #40 revealed there was no noticeable change to her breast. LPN #40 revealed Resident #37 began to whimper and cry and stated, What have I done so wrong, I tell you when I find the man that has done this to me and he won't have any balls left, he better leave his hands off of me, because I'm not the one to be messed with, I'm completely happy with my husband. LPN #40 revealed she listened to the resident and expressed to her that staff would make frequent checks and that it was safe at the facility. The nursing note revealed staff was monitoring her room and she was currently resting quietly with eyes closed and call light in reach. The nursing note revealed no further assessments that LPN #40 completed on Resident #37 for signs of abuse except for the breast exam. The nursing note revealed no notification to the Administrator or designee, physician, or responsible party regarding the allegation of abuse or no details regarding an initiation of an investigation regarding the allegation of abuse. Review of facility self- reported incidents (SRI's) revealed there was no self-reported incidents filed regarding Resident #37's incident that had occurred on 03/23/21. After the above was brought to the Administrator's attention during the survey, the Administrator filed a self-reported incident on 04/21/21 with a tracking number #205182 for Resident #37 regarding her allegation of physical and sexual abuse made on 03/23/21. Review of social service note dated 03/23/21 at 4:20 P.M. and authored by Licensed Social Worker (LSW) #115 revealed Resident #37's son was made aware of Resident #37's behaviors of increased paranoia and delusions that she had the night of 03/23/21. Resident #37 was scheduled to see Psychiatrist #600 on 03/24/21. Resident #37's son agreed to have Psychiatrist #600 see Resident #37 and if he had any ideas for treatment. LSW #115 discussed the option of a specialized mental health facility but Resident #37's son would like that to be the last resort as he loved the current facility Resident #37 was residing in. Review of Psychiatrist #600's progress note dated 03/24/21 revealed Resident #37 reported to the nurse she was sexually assaulted. He evaluated Resident #37 and made medication adjustments and ordered lab work. There was no mention of any details Resident #37 provided to Psychiatrist #600 regarding the allegation in the progress note. Phone Interview on 04/20/21 at 12:06 P.M. with the Director of Nursing (DON) verified she was not contacted immediately after Resident #37 made the allegation of physical and sexual abuse by LPN #40. She revealed she believed she was notified when she came in that morning but was not for sure when she was notified. She revealed the facility did not file a self-reported incident (SRI) regarding the incident on 03/23/21. She revealed she did investigate into the allegation but did not have any written documentation such as witness statements, or a formal investigation. Interview on 04/21/21 at 9:02 A.M. with the Administrator revealed Resident #37 had long standing psychiatric issues including making allegations of sexual abuse. She verified Resident #37 made an allegation of physical and sexual abuse on 03/23/21 and LPN #40 did not immediately notify her or any other designee of the allegation of abuse as directed in the abuse policy. She revealed she was notified when she came into the facility the morning of 03/23/21. She verified the facility should have notified her, notified the physician immediately, and the facility should have completed a self-reported incident to the State Survey Agency per the facility policy. She verified the facility did not complete a formal investigation including interviews or witness statements regarding Resident #37's alleged abuse allegation. Interview on 04/21/21 at 2:38 P.M. with Psychiatrist #600 revealed he was made aware Resident #37 had stated she was sexually assaulted. He revealed Resident #37 had a history of false allegation, paranoia, and delusions and he did evaluate Resident #37 after her allegation on 03/24/21. She had no recollection of the events that she had reported, and he gave him no details of the alleged allegation. He revealed he increased her anti-psychotic medication and since she had less delusions; he felt she was doing better. Interview on 04/22/21 at 2:02 P.M. with LPN #40 revealed Resident #37 came to the nursing station and asked to speak with her in her room. LPN #40 stated she went to Resident #37's room and Resident #37's had stated a man had physically and sexually assaulted her by smashing her boob down. Resident #37 stated it was flat and the man had touched her private area with his fingers. LPN #40 revealed she did assess her breast area, but she did not note any abnormalities on assessment. LPN #40 revealed she did not assess any other areas including Resident #37's private area. LPN #40 revealed Resident #37 was crying and was upset regarding the incident. LPN #40 revealed she did not report the allegation of abuse to the administrator, physician, or responsible party as per the abuse policy. LPN #40 revealed there was no excuse as to why she did not report, and she should have notified the administrator immediately of Resident #37's allegation of abuse. LPN #40 revealed Resident #37 made false allegations previously, so she revealed she just assumed it was another false allegation. LPN #40 revealed she did not report the allegation until change of shift on 03/23/21 at approximately 7:00 A.M. when she reported the incident either to the oncoming nurse or the Unit Manager/ Wound Nurse #24 but could not remember exactly who she reported the allegation to. LPN #40 verified she did not conduct any interviews or obtain any witness statements from other residents in the area, from other staff members, or that she initiated any investigation after Resident #37 made the allegation of abuse. Review of undated facility policy labeled, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property revealed the facility failed to implement their policy as the policy revealed the facility would investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment. The facility staff would immediately report all such allegations to the administrator and to the Ohio Department of Health. The facility in cases where a crime was suspected staff would report the allegation to the local law enforcement. The policy defines sexual abuse as non-consensual sexual contact of any type with a resident and physical abuse included but not limited to hitting, slapping, punching, biting, and kicking. The policy revealed if abuse or serious bodily injury was alleged the allegation would be reported to the Ohio Department of Health immediately but no later than two hours after the allegation was made and all other allegations involving abuse, neglect, exploitation mistreatment would be reported to the Ohio department of Health no later than 24 hours from the time the incident/ allegation was made. The policy revealed once the Administrator and the Ohio Department of Health were notified an investigation of the alleged violation would be consulted. The policy revealed the investigation would be completed within five working days. The investigation would include an interview with the resident, accused, and all witnesses by obtaining a statement from the resident if possible, the accused and each witness, and evidence of the investigation should be documented. The policy revealed the results of the investigation would be reported to the Administrator and the final report would be submitted to the Ohio Department of Health no later than five working days after discovery of the incident.

Based on interview, review of facility abuse policy and record review the facility failed to thoroughly investigate when Resident #37 alleged she was physically and sexually abused on 03/23/21. This affected one resident (Resident #37) out of one resident reviewed for abuse. This had the potential to affect all 64 residents residing in the facility. Findings included: Review of medical record for Resident #37 revealed an admission date of 10/21/20 and diagnoses included Alzheimer's Disease, delusional disorder, dementia with behavioral disturbances, and anxiety disorder. Review of care plan for Resident #37 dated 03/01/21 revealed she had the potential to demonstrate verbally inappropriate behaviors related to mental and emotional illness. She had a history of false accusations towards caregivers. Interventions included analyze key times, places, circumstances, triggers, and what escalated her behaviors and document, and psychological consult as indicated. Review of Medicare five-day Minimum Data Set (MDS) 3.0 dated 03/03/21 revealed Resident #37 had impaired cognition and she had delusions. Review of nursing note dated 03/23/21 at 12:40 A.M. and authored per Licensed Practical Nurse (LPN) #40 revealed Resident #37 came to the nursing desk and stated, I need to talk to you in my room please. LPN #40 revealed she went into Resident #37's room and Resident #37 started to cry and whimper and pulled up her shirt showing LPN #40 her right breast. Resident #37 stated A man came in here and smashed my boob down and now its flat and hanging down low, and he also fingered my down there (vagina) as she whispered the word vagina. LPN #40 revealed there was no noticeable change to her breast. LPN #40 revealed Resident #37 began to whimper and cry and stated, What have I done so wrong, I tell you when I find the man that has done this to me and he won't have any balls left, he better leave his hands off of me, because I'm not the one to be messed with, I'm completely happy with my husband. LPN #40 revealed she listened to the resident and expressed to her that staff would make frequent checks and that it was safe at the facility. The nursing note revealed staff was monitoring her room and she was currently resting quietly with eyes closed and call light in reach. The nursing note revealed no further assessments that LPN #40 completed on Resident #37 for signs of abuse except for the breast exam. The nursing note revealed no notification to the Administrator or designee, physician, or responsible party regarding the allegation of abuse or no details regarding an initiation of an investigation regarding the allegation of abuse. Review of facility self- reported incidents (SRI's) revealed there was no self-reported incidents filed regarding Resident #37's incident that had occurred on 03/23/21. After the above was brought to the Administrator's attention during the survey, the Administrator filed a self-reported incident on 04/21/21 with a tracking number #205182 for Resident #37 regarding her allegation of physical and sexual abuse made on 03/23/21. Review of social service note dated 03/23/21 at 4:20 P.M. and authored by Licensed Social Worker (LSW) #115 revealed Resident #37's son was made aware of Resident #37's behaviors of increased paranoia and delusions that she had the night of 03/23/21. Resident #37 was scheduled to see Psychiatrist #600 on 03/24/21. Resident #37's son agreed to have Psychiatrist #600 see Resident #37 and if he had any ideas for treatment. LSW #115 discussed the option of a specialized mental health facility but Resident #37's son would like that to be the last resort as he loved the current facility Resident #37 was residing in. Review of Psychiatrist #600's progress note dated 03/24/21 revealed Resident #37 reported to the nurse she was sexually assaulted. He evaluated Resident #37 and made medication adjustments and ordered lab work. There was no mention of any details Resident #37 provided to Psychiatrist #600 regarding the allegation in the progress note. Phone Interview on 04/20/21 at 12:06 P.M. with the Director of Nursing (DON) verified she was not contacted immediately after Resident #37 made the allegation of physical and sexual abuse by LPN #40. She revealed she believed she was notified when she came in that morning but was not for sure when she was notified. She revealed the facility did not file a self-reported incident (SRI) regarding the incident on 03/23/21. She revealed she did investigate into the allegation but did not have any written documentation such as witness statements, or a formal investigation. Interview on 04/21/21 at 9:02 A.M. with the Administrator revealed Resident #37 had long standing psychiatric issues including making allegations of sexual abuse. She verified Resident #37 made an allegation of physical and sexual abuse on 03/23/21 and LPN #40 did not immediately notify her or any other designee of the allegation of abuse as directed in the abuse policy. She revealed she was notified when she came into the facility the morning of 03/23/21. She verified the facility should have notified her, notified the physician immediately, and the facility should have completed a self-reported incident to the State Survey Agency per the facility policy. She verified the facility did not complete a formal investigation including interviews or witness statements regarding Resident #37's alleged abuse allegation. Interview on 04/21/21 at 2:38 P.M. with Psychiatrist #600 revealed he was made aware Resident #37 had stated she was sexually assaulted. He revealed Resident #37 had a history of false allegation, paranoia, and delusions and he did evaluate Resident #37 after her allegation on 03/24/21. She had no recollection of the events that she had reported, and he gave him no details of the alleged allegation. He revealed he increased her anti-psychotic medication and since she had less delusions; he felt she was doing better. Interview on 04/22/21 at 2:02 P.M. with LPN #40 revealed Resident #37 came to the nursing station and asked to speak with her in her room. LPN #40 stated she went to Resident #37's room and Resident #37's had stated a man had physically and sexually assaulted her by smashing her boob down. Resident #37 stated it was flat and the man had touched her private area with his fingers. LPN #40 revealed she did assess her breast area, but she did not note any abnormalities on assessment. LPN #40 revealed she did not assess any other areas including Resident #37's private area. LPN #40 revealed Resident #37 was crying and was upset regarding the incident. LPN #40 revealed she did not report the allegation of abuse to the administrator, physician, or responsible party as per the abuse policy. LPN #40 revealed there was no excuse as to why she did not report, and she should have notified the administrator immediately of Resident #37's allegation of abuse. LPN #40 revealed Resident #37 made false allegations previously, so she revealed she just assumed it was another false allegation. LPN #40 revealed she did not report the allegation until change of shift on 03/23/21 at approximately 7:00 A.M. when she reported the incident either to the oncoming nurse or the Unit Manager/ Wound Nurse #24 but could not remember exactly who she reported the allegation to. LPN #40 verified she did not conduct any interviews or obtain any witness statements from other residents in the area, from other staff members, or that she initiated any investigation after Resident #37 made the allegation of abuse. Review of undated facility policy labeled, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property revealed the facility failed to implement their policy as the policy revealed the facility would investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment. The facility staff would immediately report all such allegations to the administrator and to the Ohio Department of Health. The facility in cases where a crime was suspected staff would report the allegation to the local law enforcement. The policy defines sexual abuse as non-consensual sexual contact of any type with a resident and physical abuse included but not limited to hitting, slapping, punching, biting, and kicking. The policy revealed if abuse or serious bodily injury was alleged the allegation would be reported to the Ohio Department of Health immediately but no later than two hours after the allegation was made and all other allegations involving abuse, neglect, exploitation mistreatment would be reported to the Ohio department of Health no later than 24 hours from the time the incident/ allegation was made. The policy revealed once the Administrator and the Ohio Department of Health were notified an investigation of the alleged violation would be consulted. The policy revealed the investigation would be completed within five working days. The investigation would include an interview with the resident, accused, and all witnesses by obtaining a statement from the resident if possible, the accused and each witness, and evidence of the investigation should be documented. The policy revealed the results of the investigation would be reported to the Administrator and the final report would be submitted to the Ohio Department of Health no later than five working days after discovery of the incident.

Based on record review and interview the facility failed to develop a Hospice Care Plan for Hospice for Resident #44. This affected one of two residents reviewed for hospice (Resident #16 and Resident #44). This had the potential to affect all seven hospice residents in the facility (#16, #30, #36, #44, #45, #55, and #62). The facility census was 64. Findings Include: Medical record for Resident #44 revealed an admission date of 01/11/17. Diagnoses included malignant neoplasm of left lung and Alzheimer's disease. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/15/21, revealed the resident had severely impaired cognition. The resident required the extensive assistance for bed mobility, locomotion, dressing, toilet use and personal hygiene. Limited assistance was needed for eating. The resident was totally dependence for transfers. Review of physician orders for 04/21 identified an order for admission to hospice for malignant neoplasm of the left lung was initiated on 03/04/21. Record review revealed no hospice care plan had been developed. Interview on 04/22/21 at 11:41 with Assistant Director of Nursing (ADON) #70 verified there was no hospice care plan in the medical record.

Based on observation, interview and record review the facility failed to ensure Resident #56's dignity was maintained when a urinary drainage collection bag was not covered. This affected one resident (Resident #56) of six residents with indwelling urinary catheters. The facility census was 77. Findings include: Record review for Resident #56 revealed an admission date of 05/15/18 and diagnoses that included paraplegia, urine retention, benign prostatic hyperplasia, and history of urinary tract infections. Review of a physician order dated 05/15/18 revealed Resident #56 had an indwelling urinary to be maintained every shift due to chronic urinary retention related to benign prostatic hyperplasia. Review of Resident #56's care plan dated 09/25/18 revealed the resident had the potential for complications related to urinary catheter use due to diagnosis of benign prostatic hyperplasia, urine retention and obstructive uropathy. An intervention included position catheter bag away from the entrance from the room door or use bag cover. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 01/23/19 revealed Resident #56 was cognitively intact. He required extensive assist of two person for toilet use, extensive assist of one person for locomotion on unit, and total dependence of two person assist with transfers. He had an indwelling urinary catheter. Observation on 02/25/19 at 10:37 A.M. revealed Resident #56's indwelling urinary catheter drainage bag was hanging on the side of the bed facing the entrance to the room without a bag cover. From the hallway urine could be seen in the drainage bag. Observation on 02/26/19 at 9:17 A.M. revealed Resident #56 was sitting in a wheelchair by the nursing station with the indwelling urinary catheter drainage bag underneath the wheelchair without a bag cover and urine could be seen in the drainage bag. Interview on 02/26/19 at 9:20 A.M. with Registered Nurse #600 verified that Resident #56's urinary catheter drainage bag was not covered. Observation on 02/27/19 at 11:13 A.M. revealed Resident #56's indwelling urinary catheter drainage bag was positioned on the side of the bed towards the entrance of the room without a bag cover and from the hallway urine could be seen inside the bag. Interview on 02/27/19 at 11:13 A.M. with Licensed Practical Nurse #601 verified that Resident #56's catheter drainage bag was not covered and that from the hallway urine could be seen inside the drainage bag. Review of the undated facility policy Urinary Drainage Bag/ Urinary leg Drainage bag Cleansing During Alternating Use revealed the continuous drainage bag should be placed inside the drainage privacy bag to maintain dignity for continued socialization and mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (Resident #47) of one resident reviewed for pre admission screening and resident review (PASRR). The facility census was 77. Findings Include: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), history of falling and difficulty walking. Review of the psychiatric consult note for Resident #74 dated 02/21/18 revealed Resident #74 was given a diagnosis of major depressive disorder and violent behavior. These diagnosis were reflected and dated as such throughout Resident #74's medical record. Review of both the electronic and hard charts revealed no evidence the appropriate state agency (The Ohio Department of Mental Health) was notified of the new diagnosis for PASRR review as required. Social Service Designee #500 verified the appropriate state agency was not notified of the new diagnosis/decline in an interview on 02/28/19 at 11:32 A.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure nutritional interventions recommended per the dietitian were implemented after Resident #55 and Resident #227 had significant weight loss. This affected two residents (Resident #55 and Resident #227) of three residents reviewed for nutritional status. Findings include: 1. Record review of Resident #55 revealed an admission date of 01/16/19 and diagnoses that included unspecified severe protein calorie malnutrition, subsequent encounter for fracture with routine healing contusion of lower back and pelvis, and dementia without behavioral disturbances. Review of Resident #55's weight record revealed an admission weight on 01/16/19 of 132.6 pounds. Review of the Nutritional assessment dated [DATE] revealed Resident #55 had a low body mass index and low albumin level (protein level). Dietitian #603 indicated Resident #55 needed additional calories and protein and recommended a Magic cup (nutritional supplement) with each meal. Review of physician order for Resident #55 dated 01/17/19 revealed Magic cup with meals for supplementation. Review of Resident #55's care plan dated 01/17/19 revealed Resident #55 had a nutritional problem related to textured altered diet, illness, and infection related to low body mass index. Intervention included provide and serve supplements as ordered. Resident #55's subsequent weights were noted as: 01/19/19 - 132 pounds. 01/22/19 - 105 pounds indicating a significant weight loss of 20.45 percent. 01/22/19 a re-weigh of 105.2 pounds. 01/26/19 - 104.2 pounds. 01/28/19 - 103.8 pounds. 02/04/19 - 105.2 pounds. 02/05/19 - 100 pounds. 02/14/19 - 103.8 pounds. 02/20/19 - 107.8 pounds. Review of a 30- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had impaired cognition and required supervision with set up help only with eating. Observation on 02/26/19 at 11:57 A.M. revealed Resident #55 did not have a Magic cup on his lunch tray when served. Observation on 02/27/19 at 11:58 A.M. revealed Resident #55 did not have a Magic cup on his lunch tray. Interview with Resident #55 revealed that he had not received a Magic cup. Interview on 02/27/19 at 12:00 P.M. with State Tested Nurse Aides (STNAs) #604 and #605 revealed they were currently assigned on the unit where Resident #55 resided and they gave Resident #55 his meal tray. They indicated Resident #55 did not receive a Magic cup with his meal. They also said Resident #55 had not received the Magic cup in awhile; they thought the Magic cup was discontinued when his thickened liquids were discontinued. Interview on 02/27/19 at 12:48 P.M. with Dietary Manager #606 revealed Resident #55 was on a Regular diet and was to receive a Magic cup with his meals. Phone interview on 02/27/19 at 12:58 P.M. with Dietitian #603 verified she recommended Resident #55 receive a Magic cup with his meals due to weight loss. She was not aware that he had not been receiving his supplement as ordered. 2. Record review of Resident #227 revealed an admission date of 01/14/19 and diagnoses that included trochanteric fracture of right femur, protein- calorie malnutrition, and sepsis. Review of Resident #227's weight record revealed an admission weight on 01/14/19 of 165 pounds. Review of Resident #227's care plan dated 01/15/19 revealed he had unplanned and unexpected weight loss related to acute illness, increased nutritional and calorie needs associated with fracture injury and decreased food intake. Interventions included giving supplements as ordered and alert dietitian if not consuming on a routine basis. Review of the Nutritional assessment dated [DATE] for Resident #227 revealed decreased appetite with significant weight loss prior to admission in the last two to six months. Dietitian #604 added a Boost supplement. Review of the dietitian progress note dated 01/22/19 at 5:43 P.M. revealed Resident #227 expressed concern with recent weight loss and stated that his usual weight was 190 pounds. Resident #227 reported poor appetite. Resident #227 agreed to increase his Boost supplement to four times daily and was agreeable to have a peanut butter and jelly sandwich on each lunch and dinner tray for benefit of added calories. Review of a nursing note dated 01/23/19 at 2:03 P.M. revealed the dietitian recommended Boost supplement four times a day and a peanut butter and jelly on wheat bread per resident request for lunch and dinner. Resident #227's subsequent weights were: 01/28/19 - 157.4 pounds. 02/02/19 - 158.2 pounds. 02/12/19 - 150 pounds. 02/20/19 - 154.4 pounds. 02/26/19 - 153.6 pounds. 02/26/19 - 152.6 pounds (significant weight loss of 7.52 percent). Review of the 14- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #227 revealed he was cognitively impaired and required supervision with set up help only with eating. He had a height of 72 inches and a weight of 157 pounds with a weight loss noted that was not prescribed. Review of the Nutritional assessment dated [DATE] for Resident #227 revealed history of significant weight loss with recent hip and rib fracture from fall. Dietitian #603 indicated Resident #227 was agreeable to supplements and a peanut butter and jelly sandwich for added calories due to weight loss. Observation on 02/26/19 at 12:02 P.M. revealed Resident #227's lunch tray did not include a peanut butter and jelly sandwich. Interview on 02/26/19 at 4:34 P.M. with State Tested Nurse Aide (STNA) #607 revealed he worked on Resident #227's unit on second shift and Resident #227 did not receive a peanut butter jelly sandwich on his dinner trays unless he asked for it as an alternative to the main course. STNA #607 revealed that he was not aware Resident #227 was to receive a peanut butter jelly sandwich on his lunch and dinner trays. Observation on 02/27/19 at 11:54 P.M. revealed Resident #227 did not not receive a peanut butter and jelly sandwich on his lunch tray. Interview on 02/27/19 at 12:00 P.M. with STNAs #604 and #605 revealed they were currently assigned to the unit where Resident #227 resided. They stated Resident #227 did not get a peanut butter jelly sandwich with his lunch trays and they did not know that it was a dietitian recommendation to receive a peanut butter and jelly sandwich with his lunch and dinner trays. Interview on 02/27/19 at 12:48 P.M. with Dietary Manager #606 revealed she had recommendations from the Dietitian that Resident #227 was on a Regular diet with no added salt and was to receive a peanut butter and jelly sandwich at lunch and dinner. Phone interview on 02/27/19 at 12:58 P.M. with Dietician #603 verified Resident #227 had a significant weight loss and that her recommendation was that Resident #227 was to receive a peanut butter and jelly sandwich on his lunch and dinner tray. She verified she was not aware he was not receiving the sandwiches.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #56's indwelling urinary catheter drainage bag and tubing were not on the floor and maintained below Resident #56's bladder to prevent urine back up into the bladder. This affected one resident (Resident #56) of six residents with indwelling urinary catheters. The facility also failed to ensure staff wore gloves when administering insulin to Resident #8. This affected one of one resident observed for subcutaneous injections. Facility census was 77. Findings include: 1. Record review for Resident #56 revealed an admission date of 05/15/18 and diagnoses that included paraplegia, urine retention, benign prostatic hyperplasia, and history of urinary tract infections. Review of a physician order dated 05/15/18 revealed Resident #56 had an indwelling urinary catheter to be maintained every shift due to chronic urinary retention related to benign prostatic hyperplasia. Review of Resident #56's care plan dated 09/25/18 revealed the potential for complications related to catheter use due to diagnoses of benign prostatic hyperplasia, urine retention and obstructive uropathy. Intervention included position catheter bag and tubing below the level of the bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact. He required extensive assist of two person for toilet use, extensive assist of one person for locomotion on unit, and total dependence of two person assist with transfers. He had an indwelling urinary catheter. Observation on 02/26/19 at 9:17 A.M. revealed Resident #56 was sitting in his wheelchair with his indwelling catheter drainage bag and tubing touching the floor. Interview on 02/26/19 at 9:20 A.M. with Registered Nurse (RN) #600 verified Resident #56's indwelling urinary catheter bag and tubing was touching the floor. She indicated the wheelchair was low to the ground which caused the catheter bag and tubing to drag. Observation on 02/26/18 at 4:25 P.M. revealed Resident #56 sitting in his room in his wheelchair with his indwelling urinary catheter drainage bag on his lap. Resident #56 revealed staff unhooked his urinary catheter drainage bag and put the drainage bag on his lap. Resident #56 revealed that he had been waiting twenty minutes for staff to come back to lay him in bed. Interview on 02/26/18 at 4:28 P.M. with State Tested Nursing Assistant (STNA) #603 verified the indwelling urinary catheter drainage bag was placed on Resident #56's lap. STNA #603 indicated she did not know who placed the drainage bag on his lap but that it should not have been placed on the resident's lap. STNA #603 said Resident #56 had returned from dialysis about twenty minutes ago and was waiting for staff to transfer him to his bed. Interview on 02/28/19 at 1:42 P.M. with the Director of Nursing verified that indwelling urinary catheter drainage bags should be maintained below the resident's bladder and the drainage bag or tubing should not touch the floor to prevent the risk of bladder infections. 2. Observation of a medication administration for Resident #8 by Licensed Practical Nurse (LPN) #201 on 02/27/19 at 11:22 A.M. revealed the nurse did not wear gloves while administering a subcutaneous injection of insulin to the resident. Interview with LPN #201 on 02/27/19 at 11:40 A.M. confirmed the above findings. LPN #201 confirmed she should have worn gloves when administering subcutaneous injections. Review of the facility infection control policy concerning glove-wearing dated 08/2009 revealed gloves were to be worn when it was likely the employee's hands would come in contact with body fluids or non-intact skin, as well as during all invasive procedures.