Every finding on record at Bethlehem Woods Nursing and Rehabilitation

Based on observation and record review the facility failed to ensure proper labeling/storage were completed for 3 of 3 medication carts reviewed. This affected 7 of 7 residents reviewed. (Resident 20, Resident 2, Resident 9, Resident 62, Resident 6, Resident 75, and Resident 94) Findings include: During an observation, on 3/26/26 at 11:08 AM, on the 200-hall cart, Resident 20 had an open bottle of liquid potassium chloride 10%, it did not have an open date. During an observation, on 3/26/26 at 11:14 AM, on the 300-hall (front) cart, Resident 2 had an open bottle of Guaifenesin 100 milligrams (mg)/15 milliliter (ml), there was no open date. Resident 9 had an open bottle of Guaifenesin liquid 100mg/5ml, there was no open date observed. Resident 62 had an open bottle of: Biotene Dry mouth, there was no open date observed. Resident 6 had an open bottle of lidocaine 1% vial with no open date. In an interview, on 3/26/26 at 11:20 AM, the Director of Nursing (DON) indicated the lidocaine should have been taken off the cart as it was used for Resident 6's antibiotic and he was not on it anymore.During an observation, on 3/26/26 at 11:23 AM, on the 300-hall (back) cart, Resident 75 had an open bottle of chlorhexidine 0.12%, there was no open date. Resident 94 had an open bottle of lactulose 10 gm/15 ML, there was no open date. Resident 6 had an open bottle of Guaifenesin 100 mg/15 ml, with no opened date observed. In an interview, on 3/26/26 at 11:26, the DON indicated the nurse who opened the medication should have put an open date on the medications.1. Resident 20's record was reviewed on 3/27/26 at 10:00 AM. Diagnoses included Dementia with psychotic disturbance.A review of physician orders indicated to give potassium chloride liquid 20 milliequivalent (mEq)/15 mL, give10 mEq. This order was discontinued(d/c) on 3/29/26.2. Resident 2's record was reviewed on 3/27/26 at 10:15 AM. Diagnoses included Aphasia following cerebral infarction-expressive aphasia.A review of physician order indicated, to give guaifenesin liquid,100 mg/5 mL, 200mg/ 10ml. This order was d/c on 03/26/2026.3. Resident 9's record was reviewed on 3/27/26 at 10:20 AM. Diagnoses included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A review of the physician order indicated to give guaifenesin liquid, 100 mg/5 mL, give 20ml. This order was d/c on 3/26/26.4. Resident 62's record was reviewed on 3/27/26 at 10:30 AM. Diagnoses included Paroxysmal atrial fibrillation. A review of the physician order, dated 06/09/202, indicated to administer Biotene Dry Mouth Oral Rinse 15 mL daily. 5. Resident 6's record was reviewed on 3/27/26 at 10:45 AM. Diagnoses included Malignant neoplasm of right kidney.A review of the physician order indicated to administer guaifenesin liquid 100 mg/5 mL, give 20 mL, this medication was d/c on 3/26/26. The lidocaine hydrochloride (hcl) 1% vial, not have a current order. 6. Resident 75's record was reviewed on 3/27/26 at 10:55 AM. Diagnoses included Chronic obstructive pulmonary disease, unspecified.A review of the physician order indicated to administer chlorhexidine gluconate mouthwash 0.12%, give 1/2 ounce (oz). This medication was d/c on 3/26/26.7. Resident 94's record was reviewed on 3/27/26 at 11:05 AM. Diagnoses included Syncope and collapse. This resident was discharged from the facility on 03/15/2026.A current facility policy, Medication Storage and policy, dated 11/24, provided by the DON on 3/26/26 indicated. the facility should store medications and monitor expiration dates of medications consistent with applicable state and federal laws and regulations. 410 IAC (Indiana Administrative Code) 16.2-3.1-3.1-25 (j)

Based on interview and record review the facility failed to ensure medications were administered as ordered for 1 of 3 residents reviewed (Resident B).Findings include:In an interview on 3/18/26 at 10:30 AM, Resident B indicated he did not receive his medications as ordered.Resident B's record was reviewed on 3/18/26 at 12:05 PM. Diagnoses included hypertension and type 2 diabetes mellitus.Resident B's Medication Administration Record (MAR), dated 2/26/26-3/10/26, indicated Resident B had an order for clonidine HCl (antihypertensive) 0.5 mg to be given twice a day orally. The MAR indicated Resident B did not receive clonidine HCl from on any day 2/26/26 -3/10/26 due to awaiting delivery from the pharmacy.Resident B's nursing notes, dated 2/26/26 - 3/10/26, did not indicate the pharmacy or Nurse Practitioner (NP) was notified Resident B had not received clonidine medication as ordered due to awaiting pharmacy delivery.In an interview, on 3/18/26 at 11:33 AM, Registered Nurse (RN) 2 indicated when a medication had not been delivered by the pharmacy, the nurse should call the pharmacy for updates and continue to update the resident and NP on the status of delivery.In an interview, on 3/19/26 at 9:14 AM, the Director of Nursing (DON) indicated Resident B was admitted on Thursday afternoon. On Friday the nurse placed a note in the NP book for Resident B to be seen on Monday 3/2/26. The DON indicated on Monday, there was a lack of communication, and the missed clonidine medication was not addressed. The DON indicated the pharmacy indicated they did not receive any additional communication via phone or fax from the facility regarding Resident B's medication. The DON indicated when a medication is not delivered from the pharmacy the nurse should call the pharmacy and send a fax requesting the medication.A current policy, last revised 4/2025, titled Medication Administration, was provided by the DON on 3/19/26 at 10:02 AM. The policy indicated medications should be administered 1 hour before or 1 hour after the ordered time. The policy did not indicate the protocol for missing medications from the pharmacy.This citation relates to Intake 2797186.410 16.2 3.1-37

Based on interview and record review the facility failed to perform admission agreements in a timely manner for 3 of 3 residents reviewed. (Resident Q, Resident R, and Resident S).Findings include: 1) Resident Q's record was reviewed on 11/17/25 at 9:26AM. Resident Q was admitted on [DATE].Resident Q's admission agreement paperwork was signed on 10/29/25, 4 days after admission. The admission agreement was dated 10/25/25 and included the following: Resident obligations, Consent for Treatment, Services, Payments for Room Rate, Medicare and Medicaid Programs, Personal Finances, Termination Transfers and Discharges, Bed Hold Policy, Personal Property, Resident Records, Privacy, Non-Discrimination, Dispute Resolution, Limitations of Community, Miscellaneous Provisions and signatures.In an interview, on 11/17/25 at 12:57PM, the Executive Director (ED) indicated Resident Q's daughter was not available on 10/27/25 or 10/28/25 to sign the paperwork. After reviewing Resident Q further, it was determined the resident was able to sign her own admission paperwork on 10/29/25.2) Resident R's record was reviewed on 11/17/25 at 11:31AM. Resident R was admitted on [DATE].Resident R's admission agreement paperwork was signed on 10/20/25, 3 days after admission, by her daughter and Power of Attorney (POA). Resident R's admission agreement was signed by Resident R on 11/6/25. The admission agreement was dated 10/17/25 and included the following: Resident obligations, Consent for Treatment, Services, Payments for Room Rate, Medicare and Medicaid Programs, Personal Finances, Termination Transfers and Discharges, Bed Hold Policy, Personal Property, Resident Records, Privacy, Non-Discrimination, Dispute Resolution, Limitations of Community, Miscellaneous Provisions and signatures.3) Resident S's record was reviewed on 11/17/25 at 10:27AM. Resident S was admitted on [DATE].Resident S's admission agreement paperwork was signed on 10/27/25, 9 days after admission. The admission agreement was dated 10/18/25 and included the following: Resident obligations, Consent for Treatment, Services, Payments for Room Rate, Medicare and Medicaid Programs, Personal Finances, Termination Transfers and Discharges, Bed Hold Policy, Personal Property, Resident Records, Privacy, Non-Discrimination, Dispute Resolution, Limitations of Community, Miscellaneous Provisions and signatures.In an interview, on 11/17/25 at 12:57PM, the ED indicated Resident S's wife was sick, not available on 10/24/25 and did not attend the planned meeting (6 days after admission). Resident S's wife was sick and unavailable until 10/27/25 when she signed the admission paperwork.In an interview, on 11/17/25 at 10:30AM, the ED indicated there was implied consent until an admission agreement can be made, especially when someone comes in on a weekend or late in the evening.No policy or procedure was available at time of exit.

Based on interview and record review, the facility failed to ensure the documentation of required information for hospital transfers was present for 1 of 2 residents reviewed (Resident 24). Findings include: Resident 24's record was reviewed on 5/14/25 at 9:57 AM. Diagnoses included end stage kidney disease, heart failure and emphysema. Resident 24 had a cardiac pacemaker and was dependent on dialysis. Resident 24's Annual Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 14 (no cognitive impairment). A progress note, dated 8/24/24 at 7:40 PM, indicated Resident 24 had been transferred to the hospital. The progress note indicated the receiving hospital had been notified. The progress note did not indicate Resident 24's family had been notified. An Event Report, dated 8/24/24 at 8:04 PM, indicated Resident 24's Representative had been notified of a hospital transfer. The Event Report did not include the Representative's name or contact information. A Notice of Transfer or Discharge, dated 8/24/24, indicated Resident 24 had been transferred to the hospital. The Notice of Transfer or Discharge indicated the facility must attach a copy of the facility's bed hold policy. The Notice of Transfer or Discharge did not include a bed hold policy. A progress note, dated 9/11/24 at 12:30 PM, indicated Resident 24 had requested to go to the hospital and the ambulance was on the way. The progress note did not indicate Resident 24's family had been notified of the hospital transfer. A Notice of Transfer or Discharge, dated 9/11/24, indicated Resident 24 had been transferred to the hospital. The Notice of Transfer or Discharge indicated the facility must attach a copy of the facility's bed hold policy. The Notice of Transfer or Discharge did not include a bed hold policy. A progress note, dated 12/16/24 at 8:47 AM, indicated Resident 24 had been transferred to the hospital. The progress note did not indicate Resident 24's family had been notified of the hospital transfer. A Notice of Transfer or Discharge, dated 12/16/24, indicated Resident 24 had been transferred to the hospital. The Notice of Transfer or Discharge indicated the facility must attach a copy of the facility's bed hold policy. The Notice of Transfer or Discharge did not include a bed hold policy. A progress note, dated 12/27/24 at 11:45 AM, indicated Resident 24's wife had been notified of the resident being transferred to the hospital. A Notice of Transfer or Discharge, dated 12/27/24, indicated Resident 24 had been transferred to the hospital. The Notice of Transfer or Discharge indicated the facility must attach a copy of the facility's bed hold policy. The Notice of Transfer or Discharge did not include a bed hold policy. In an interview, on 5/15/25 at 1:59 PM, Registered Nurse (RN) 3 indicated copies of medical records including medications, physician orders, diagnoses and a transfer form to hold the bed should be sent with the resident to the hospital. RN 3 indicated the receiving facility would be given a report on the resident via phone. RN 3 indicated documentation should include who received the report and what records were sent. In an interview, on 5/19/25 at 10:38 AM, the Director of Nursing (DON) indicated they were unable to locate bed hold notices for Resident 24's hospital transfers. The DON provided a bed hold policy within the admission agreement signed by Resident 24 on 2/5/24. The DON indicated they were unable to locate any further family notifications. In an interview, on 5/19/25 at 11:05 AM, RN 25 indicated a family member should be notified when a resident is transferred to the hospital. RN 25 indicated Resident 24's spouse was always aware of new orders as their spouse was in the facility a lot. RN 25 indicated Resident 24 often updated their spouse themselves. A current facility policy, dated 6/7/17, titled Emergency Transfer Notifications, provided by the DON on 5/19/25 at 11:45 AM, indicated the transfer information may be provided to the resident and their representative as soon as practicable. The policy indicated the nursing staff would inform the family member of the transfer. The policy indicated a bed hold policy would be reviewed with the responsible party and would be documented in the medical record. 3.1-12(a)(21) 3.1-12(a)(25)(26)

Based on observation, interview, and record review the facility failed to be free of physical restraint for 1 of 1 resident reviewed. (Resident 29) Finding include: During an observation, on 4/26/23 at 10:04AM, Resident 29 was in the dining room of the memory care unit. Resident 29 was sitting in a chair with arms. The chair was up against a partial wall and the table was pulled up flush to Resident 29's stomach. There were peers in wheelchairs on each side of Resident 29 during this observation. Resident 29 could not get up, or away from the table. During an observation on 4/28/23 from 10:36AM to 11:05AM, Resident 29 was sitting in the armed chair in dining room. The chair was up against a partial wall and the table was pulled up flush to Resident 29's stomach. There were peers in wheelchairs on each side of Resident 29 during this observation. In an interview on 4/28/23 at 10:56AM, RN 15 (Registered Nurse), indicated a restraint was the inability to move freely. The RN gave the example of someone in a wheelchair with the wheels locked and resident unable to unlock them. RN 15 indicated Resident 29 was restrained by the table, but I don't know what to do about it. In an interview on 4/28/23 at 11:02AM, RN 17 indicated the incident described above was a physical restraint. In an interview on 4/28/23 at 11:16AM, with the RN 16, she indicated the issue has been resolved and the resident was currently sitting with a staff member for safety. Resident 29's record review, on 04/27/23 at 11:23 AM, indicated Resident 29 diagnoses included Alzheimer's, dementia, depression, and anxiety. Resident 29 had no care plan for restraints. Resident 29 did not have a doctor's order for restraints. Resident 29 did not have any progress notes or tracking observations regarding restraints during these observations. Resident 29's most recent MDS (Minimal Data Set assessment) included the following: Section C: BIMS assessment (Brief Interview for Mental Status) score was two. The BIMS score of 2 indicated severe cognitive impairment. Section P: Restraints and Alarms indicated there was no use of restraints or alarms at time of assessment. A policy was received on 4/28/23 at 2:03PM from DON (Director of Nursing) titled, Physical Restraint Policy original date of 6/2013 and last revision date of 11/2017. The policy stated .to ensure residents are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. If a physical restraint is used, the facility must use the least restrictive restraint for the least amount of time. Provide ongoing evaluation of the need for the restraint .Examples of facility practices that meet the definition of starting include, but not limited to: .Placing a chair or bed close enough to a wall that the resident is prevented from rising out of chair or voluntarily getting out of bed .procedure: 4. A physician's order will be obtained and will include the type, duration, frequency, and the medical condition or symptom (s) warranting the device use. 6. The resident or family member will sign the restrictive device notification form at the next visit or verbal consent may be obtained. 7. A restraint release record will be initiated to document that the resident is checked every hour .8. The care plan will be updated to include the reason for restraint use and reduction plans. The care plan must focus on preventing adverse effects of restrictive device use 3.1-3(w)

Based on observation, record review and interview, the facility failed to ensure care plans were developed and implemented for 2 of 2 residents reviewed with communication deficit. (Resident 68 and Resident 21). Finding include: 1) Resident 68's record was reviewed on 04/28/23 9:39 AM. Diagnoses included cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia - oropharyngeal phase - following cerebral infarction, and encephalopathy. Resident 68's quarterly Minimum Data Set (MDS) assessment, dated 3/3/23, indicated the resident's Brief Interview for Mental Status (BIMS) score was 11, he was confused and not interviewable. The MDS assessment indicated he had unclear speech and could be usually understood. The resident experienced shortness of breath when laying flat and was on oxygen therapy while a resident at the facility. Resident 68's admission MDS assessment, dated 11/18/22, indicated the Care Area Assessment (CAA) Summary triggered a care area of cognitive loss for care planning decisions. There was no indication Communication deficit was considered in this area. During an interview on 4/26/23 at 9:28 AM, Resident 68's speech was slurred, garbled, and could not be understood approximately 90% of the time. During an interview on 4/28/23, the Director of Therapy indicated Resident 68 had been in speech therapy off and on since November 2022. She indicated recently, therapy began 2/13/23. She indicated staff should use simple questions with yes or no answers to communicate with the resident. Resident 68's current care plan, dated 4/26/23, was reviewed. There was no care plan for the resident's cognitive loss (provided the problem, a goal, and actions for staff to do to help the resident reach his full ability) or to address the resident's communication deficit. 2) Resident 21's record was reviewed on 04/28/23 at 2:47 PM. Diagnoses included cognitive communication deficit, Parkinson's disease, disorientation, and hallucinations. Resident 21's comprehensive MDS assessment, dated 3/22/23, indicated the resident's BIMS score was 6. He was not interviewable. The MDS assessment indicated he had clear speech and could be understood. The MDS assessment indicated he had diabetes mellitus. The Care Area Assessment (CAA) Summary triggered the care area of cognitive loss for care planning decisions. There was no indication Communication deficit was considered in this area. During an interview on 4/26/23 at 9:50 AM, Resident 21 was pounding on the wall and did not respond to questions. During an interview on 4/28/23 at 2:52 PM, RN 4 indicated Resident 21 answered simple questions with a yes or no. Resident 21's current care plan, dated 4/26/23, was reviewed. There was no care plan to address the resident's communication deficit. In an interview with the Regional Nurse Consultant (RNC) 3 on 4/28/23 at 12:40 PM, she indicated she could not locate a care plan for cognitive loss for Resident 68 or Resident 21. She indicated both residents had a diagnosis of cognitive communication deficit and should had had a cognitive loss care plan. On 5/3/23 at 10:40 AM, policy titled IDT Comprehensive Care Plan Policy, dated reviewed 10/2019, provided by RN 2, indicated the comprehensive care plan was to be person-centered and based on the resident assessment to promote their highest level of functioning including medical, nursing, mental, and psychosocial needs. The care plan was to be reviewed on a regular basis about the resident's goals, total health status, including functional status, rehabilitation and restorative status, physical impairments and should include care and services to maintain and restore health and well-being, improve functional level, and relieve symptoms.

Based on interview, and record review, the facility failed to ensure minimum data set (MDS) assessment information was submitted in a timely manner for 4 of 11 records reviewed. (Resident 6, Resident 70, Resident 71, and Resident 76) Findings include: 1. The clinical record for Resident 6 was reviewed on 2/26/2020. The MDS 3.0 Resident Assessments indicated the most recent annual assessment had been completed on 1/1/2020 and was accepted with warning. The facility transmission file listing report indicated the 1/1/2020 assessment was submitted on 2/14/2020. The report indicated this submission was after 14 days of the care plan completion date. 2. The clinical record for Resident 70 was reviewed on 2/26/2020. The MDS 3.0 Resident Assessments indicated the most recent annual assessment had been completed on 1/10/2020, was in process and the 10/10/2019 quarterly assessment was accepted with warning. The facility transmission file listing report dated 1/30/2020 indicated the quarterly assessment was submitted on 1/30/2020. The report failed to indicate this submission was within 14 days of the care plan completion date. 3. The clinical record for Resident 71 was reviewed on 2/26/2020. The MDS 3.0 Resident Assessments indicated the most recent quarterly assessment had been completed on 1/10/2020, but was still in process, and the 10/10/2019 quarterly assessment was accepted with warning. The facility transmission file listing report dated 1/30/2020 indicated the assessments was submitted on 1/30/2020. The report failed to indicate this submission was within 14 days of the ARD. 4. The clinical record for Resident 76 was reviewed on 2/26/2020. The MDS 3.0 Resident Assessments indicated the most recent quarterly assessment had been completed on 1/10/2020, was in process and the 10/10/2019 Admission assessment was accepted with warning. The facility transmission file listing report dated 1/30/2020 indicated the assessment was submitted on 1/30/2020; The report failed to indicate this submissions was within 14 days of the care plan completion date. During an interview on 2/26/2020 at 11:46 A.M., the MDS coordinator was asked if the in process for the annual meant it was late; she indicated it was. She indicated the dates on the upper right hand corner of the transmission file reports were the dates of submission, she knew they were late and there was no other excuse except that she was new to the position. The facility document titled RAI OBRA-required Assessment Summary, dated October 2019, stated Transmission Date No Later Than . Admission Care Plan Completion Date + 14 calendar days . Annual . Care Plan Completion Date + 14 calendar days . Quarterly . MDS Completion Date + 14 calendar days. No State Rule

Based on observation, interview, and record review the facility failed to ensure a security bracelet was ordered or monitored for functioning and placement for 1 of 1 residents reviewed with elopement risk (Resident 57). Findings include: The clinical record for Resident 57 was reviewed on 2/25/20 at 9:23 A.M. [DIAGNOSES REDACTED]. A care plan problem initiated on 9/9/19, indicated Resident 57 was an elopement risk and he wore a secure care bracelet. An elopement risk assessment dated [DATE], indicated Resident 57 was an elopement risk and a security bracelet had been assigned to the resident. An elopement risk assessment dated [DATE], indicated Resident 57 was elopement risk and a security bracelet had been assigned to the resident. During an observation on 2/25/20 at 11:21 A.M., Resident 57 had a security bracelet on his left ankle. During an observation with the Director of Nursing Services (DNS) on 2/25/20 at 2:29 P.M., Resident 57 had a security bracelet on his left ankle. There was no documentation to indicate Resident 57's security bracelet had been ordered by a physician, monitored for placement, or checked for functioning since it had been placed in September of 2019. Registered Nurse (RN) 6 was interviewed on 2/25/20 at 1:44 P.M. During the interview RN 6 indicated security bracelets are checked for functioning daily with a machine and placement is checked each shift. RN 6 indicated orders in the computer prompt staff to check for functioning and placement of security bracelets. These checks are documented in the Medication Administration Record [REDACTED] The Director of Nursing Services was interviewed on 2/25/20 at 2:17 P.M. During the interview the DNS indicated security bracelets are ordered by the physician, are checked for placement every shift, and checked for functioning daily. The DNS also indicated security bracelet checks are documented in the MAR. The DNS was interviewed on 2/26/20 at 12:06 P.M. During the interview the DNS indicated Resident 57 had been wearing a security bracelet since September of 2019. She also indicated there were no orders for Resident 57's security bracelet, there was no documentation indicating the security bracelet had been checked for function daily or that its placement had been checked every shift since it had been placed. A policy, dated 10/2017, was provided by the DNS on 2/25/20 at 3:25 P.M., titled Elopement Prevention and Response Program. The policy indicated .2. Residents at risk for elopement may utilize a security bracelet (if the facility utilizes an electronic monitoring system and need for device is present on the care plan) per physician's orders [REDACTED]. Security bracelets are placed on resident appropriately and per manufacturer's instruction. 3.1-45(a)

Based on observation, interview, and record review the facility failed to ensure staff primed an insulin pen needle prior to use for 1 of 2 residents (Resident 77) Findings include: During an observation of medication pass, on 2/25/20 at 12:01 P.M., Registered Nurse (RN) 6 prepped 10 units of insulin in a pen for Resident 77. RN 6 wiped the end of the insulin pen with an alcohol swab, placed the needle on the end of the pen and dialed 10 units. The insulin was then injected subcutaneously into Resident 77's left upper arm. The insulin pen needle was not observed to be primed before use. During an observation of Licensed Practical Nurse (LPN) 7 on 2/26/20 at 11:12 A.M., 3 units of insulin were prepared in a pen for Resident 12. LPN 7 wiped the end of the insulin pen with an alcohol swab, placed the needle on the end of the pen and dialed 4 units. LPN 7 pressed the end of the insulin pen and the dial went to 2. The pen was then dialed to 3. The 3 units of insulin were injected subcutaneously into Resident 12's right upper arm. The insulin pen needle had been primed prior to use. Licensed Practical Nurse (LPN) 9 was interviewed regarding the use of insulin pens on 2/26/20 at 11:21 A.M. During the interview LPN 9 indicated she would clean the end of the insulin pen with an alcohol swab, place the needle on the pen, dial the pen to the number of units the resident should receive and then give the insulin. LPN 9 did not indicate she would prime the insulin pen needle prior to use. Registered Nurse (RN) 10 was interviewed regarding the use of insulin pens on 2/26/20 at 11:39 A.M. During the interview RN 10 indicated she would clean the end of the insulin pen with an alcohol swab, place the needle on the pen, dial the pen to the number of units the resident should receive and then give the insulin. RN 10 did not indicate she would prime the insulin pen needle prior to use. The Director of Nursing Services (DNS) was interviewed on 2/26/20 at 2:00 P.M. During the interview the DNS indicated insulin pen needles should be primed before use. A policy, dated 10/2019, was provided by the DNS on 2/26/20 at 1:44 P.M., titled Insulin Pen Administration. The policy indicated .7. Wipe top of insulin pen with alcohol swab/pad if instructions indicate. 8. Attach pen needle by twisting the needle onto end of insulin pen. 9. Pull off and remove outer pen needle protective cap and cover. 10. Prime the pen by dialing 2 units. 11. Push the end of the pen to push out the 2 units. (A small drop of insulin should be visible. If insulin does not appear, repeat). 12. Dial desired insulin dosage to be administrated to resident. 3.1-25

Based on observation and record review, the facility failed to follow physician recommendations for 1 of 3 residents reviewed for following physician orders [REDACTED]. Findings include: On 2/21/19 at 11:54 A.M., Resident G's record was reviewed. [DIAGNOSES REDACTED]. A significant change MDS (Minimum Data Set) assessment, dated 1/8/19, indicated the resident had a BIMS (Brief Interview Mental Status) score of 3 which signified severely impaired cognition. The MDS indicated the resident had behavioral symptoms not directed at others 4 -6 days of the assessment. He required extensive assistance from 2 staff members for bed mobility, transfers, toileting, and personal hygiene and was non-ambulatory. He currently had 2 arterial ulcers located on both his right and left heels. On 2/22/19 at 9:38 A.M., Resident G was observed sitting in his room in a high back wheelchair (w/c). A CNA (Certified Nurse Assistant) student had just finished shaving him. His feet were observed with non skid socks on and rested on a foot buddy that was attached to the pedals of his w/c. His feet were not elevated and he wore no prevalon boots. The CNA student indicated the resident had prevalon boots but that the resident always took them off. On 2/22/19 at 11:05 A.M., Resident G was observed sitting in his high back wheelchair in the hallway. His feet remained resting on a foot buddy and were not elevated. He wore no prevalon boots or other pressure relieving devices to his feet. A Care Plan, dated 3/2/17 and revised on 2/19/19, indicated the resident was at risk for skin breakdown or further skin breakdown. Interventions included, but were not limited to, foot buddy to wheelchair and encourage to float heels when in bed. A Care Plan, dated 9/13/18 and revised on 2/19/19, indicated the resident had impaired skin integrity with arterial ulcers to his right and left heels. Interventions included, but were not limited to, encourage prevalon boots to both heels. A Wound NP (Nurse Practitioner) progress note, dated 1/15/19 at unknown time, indicated the resident was seen for follow up on his wound to both heels. Assessment: Unstageable right heel pressure ulcer, Unstageable pressure ulcer to left heel, Arterial insufficiency with ischemic ulcer, and [MEDICAL CONDITION]. Plan: An arterial ultrasound was to be completed due to slow healing of the right heel ulcer. The resident had restless leg syndrome and would kick off his prevalon boots when in bed. A Wound NP progress note, dated 1/30/19 at unknown time, indicated the resident was seen for follow up on his heels. Both heel wounds were surgically debrided (damaged tissue removed from a wound) during the visit. Plan: The NP was still waiting for results of the arterial ultrasound that was to be completed on his right leg due to the right heel wound not healing. The arterial ultrasound was obtained on 2/4/19 and indicated the resident had severe arterial insufficiency to his right leg. An NP progress note, dated 2/5/19 at unknown time, indicated the resident was seen by the medical NP to review the results of the arterial ultrasound that had been ordered by the wound NP. The note indicated the resident was often seen removing his prevalon boots/heel protectors from his feet and even removing or disturbing his heel dressings. Plan: The resident's history of arterial insufficiency reports was reviewed. The residents current right heel ulcer was an ischemic ulcer related to arterial insufficiency and his left heel was a chronic ulcer related to arterial insufficiency. It was reviewed with nursing staff, the need to eliminate pressure to the resident's feet/heels/and bony prominences of his lower extremities as pressure in an extremity that suffers from arterial insufficiency is at extreme high risk for ulceration. Recommend he have his heels off loaded even when in wheelchair. For his restless leg syndrome, Requip (medication to treat restless leg syndrome) was ordered to help keep him comfortable and keep him from inadvertently removing his dressings. The recommendation to off load the pressure to the residents extremities while up in the wheelchair was not care planned nor was it placed on the TAR (Treatment Administration Record) to be monitored when the resident was in the wheelchair. There were no interventions put into place to assure his heels would be elevated and pressure relieved from his heels. The TAR for (MONTH) 2019 indicated, by nurse initials, that the resident wore his prevalon boots every shift and every day and had no refusals to wear them. On 2/22/19 at 12:00 P.M., the Director of Nursing Services (DNS) provided a current copy of the facility's policy titled Skin Management Program which stated the following: Policy: It is the policy of (facility) to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing .Procedure for Wound Prevention .3. Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk factors to include but not limited to the following .redistribute pressure (such as repositioning, protecting and/or offloading heels) .4. Residents identified at risk for pressure ulcer/injury and those with pressure ulcer/injury will have an individualized care plan developed with specific risk factors and contributing factors including preventative measures. Direct care givers will be notified of the resident specific prevention interventions .For a resident who declines treatment the IDT or designee must discuss with the resident or resident representative, the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility is expected to address the resident concerns and offer relevant alternatives if the resident has declined the specific treatments This Federal tag relates to Complain IN 967. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to implement pain management interventions for 1 of 3 residents reviewed with pain (Resident F). Findings include: On 2/21/19 at 11:31 A.M., Resident F's record was reviewed. [DIAGNOSES REDACTED]. The resident was recently hospitalized [DATE] to 1/28/19 for pneumonia. A significant change MDS (Minimum Data Set) assessment, dated 2/4/19, indicated Resident F's BIMS (Brief Interview Mental Status) score was 3 which signified severely impaired cognition. During the assessment, the resident was observed to be physically abusive to staff on a daily basis but had no rejection of care. He was observed to have non-verbal pain indicators on 1 - 2 days. He required extensive assistance from 2 staff members for bed mobility, transfers, toileting, and personal hygiene. The resident was always incontinent of bowel and bladder. A Care Plan, dated 6/14/17, indicated the resident had pain related to impaired mobility, [MEDICAL CONDITION], gout, and chronic joint pain. Interventions included, but were not limited to, administer meds (medications) as ordered, assist with positioning to comfort, document effectiveness of PRN (as needed) medications, notify the physician if pain is unrelieved and/or worsening, observe for non-verbal signs of pain such as mood and behavior changes, and offer non-pharmacological interventions such as a quiet environment, rest, shower, back rub, and re-position. A Care Plan, dated 1/31/19, indicated Resident F had impaired skin integrity to his left heel (vascular ulcer) and MASD to his natal cleft/buttocks. Interventions included, but were not limited to, assess for pain, treat as ordered and notify the physician of unrelieved/worsening pain. On 2/21/19 at 1:55 P.M., Resident F was observed lying in a low bed on his back with his feet elevated on pillows. His eyes were closed and he appeared to be sleeping. He had no non-verbal indicators of pain. On 2/22/19 at 9:33 A.M., the resident was observed in his room sitting in a wheelchair. Both feet were resting on the floor. His left foot was half covered with a non-skid sock and his heel was wrapped in gauze and resting on the floor. The resident denied pain in his left foot when questioned. When questioned about pain on his bottom, he indicated by shaking his head yes and answered his bottom hurt when staff assisted him with personal hygiene. A Physician order, dated 3/30/18, was for [MEDICATION NAME] (Tylenol) 500 mg (milligrams); give 2 tablets by mouth 2 times per day for chronic right hip pain. The MAR (Medication Administration Record) for (MONTH) 2019, indicated [MEDICATION NAME] had been administered between 7 a.m. - 11 a.m. and 5 p.m. - 10 p.m. every day as ordered. A TAR (Treatment Administration Record) for (MONTH) 2019, indicated Theraworks wound cleanser to the buttocks was applied every shift from 6 a.m. - 2 p.m., 2 p.m. - 10 p.m., and 10 p.m. - 6 a.m. The treatment to the residents natal cleft was completed daily from 6 a.m. - 2 p.m. The treatment to the resident's left heel was completed 2 times per day from 6 a.m. - 2 p.m. and 10 p.m. - 6 a.m. Nurse Notes indicated the following: 1/28/19 at 8:36 p.m., the resident readmitted to the facility from the hospital. He was agitated when staff provided evening care. He had a wound to his coccyx area which was very sensitive when the area was being cleaned. 1/29/19 at 8:17 p.m., the resident had gotten agitated at times with care, especially when changing. 1/30/19 at 5: 32 a.m., Resident F was agitated with care. Staff were able to get his brief half on. 1/30/19 at 8:21 p.m., resident was incontinent of bowel and bladder. He gets agitated with care and his coccyx area is painful. 2/2/19 at 9:35 p.m., dressing to left foot was intact. The area on the resident's bottom was cleaned with Theraworks per orders. The area had a yellow center and drained in his brief. The area was uncomfortable to the resident especially when the area was cleaned. He was aggressive with care. 2/14/19 at 1:31 p.m., Resident allowed the dressing to his left heel be changed but refused treatment to his buttocks. 2/15/19 at 4:42 p.m., the resident stated ouch that hurts at the left heel site. Nurse Practitioner (NP) progress notes indicated the following: 2/5/19 at unknown time, the resident was seen for a change in his care. The resident had been combative with care and had hit the CNA (Certified Nurse Assistant) when being turned in bed for hygiene. He was passive in between care. The resident was not eating much. His behaviors symptoms were intermittent and inconsistent, occurring every day, and generally were related to personal care. 2/12/19 at unknown time, the resident was seen due to abnormal ultrasound of the left lower extremity. His left heel was darkened with an eschar cap. He had MASD to his buttocks and coccyx. The resident complained of pain to his buttocks but was unable to give details or use a pain scale. The resident's buttocks were examined and he was found to have MASD with excoriated areas to both buttocks primarily along the gluteal cleft extending down to but not including the scrotum. The areas were very tender to touch per the resident. On 2/21/19 at 2:06 P.M., LPN 3 (Licensed Practical Nurse) was interviewed. During the interview, she indicated Resident F complained of pain to his buttocks and left heel when treatments were done. She indicated the resident would verbally say he was in pain or would have non-verbal indicators of pain such as frowning and grimacing when the open areas were touched. The resident did not receive any PRN pain medication prior to his treatments. On 2/22/19 at 12:00 P.M., the Director of Nursing Services (DNS) provided a current copy of the facility's policy titledPain Management which stated the following: It is the policy of (facility) to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, including pain management .5. The physician will be notified of unrelieved or worsening pain .11. The licensed nurse will monitor the efficacy of the [MEDICATION NAME] and keep the physician informed of any indicators of drug or dosage change as it relates to the resident's pain management relief policy. This Federal tag relates to Complaint IN 967. 3.1-37(a)

Based on interview and record review the facility failed to ensure severe weight loss was reported to the Registered Dietitian for 1 of 3 residents reviewed for nutrition (Resident 64). Findings include: The record for Resident 64 was reviewed on 2/8/19 at 9:35 A.M. [DIAGNOSES REDACTED]. A Registered Dietitian progress note dated 10/15/18, indicated Resident 64 had a 2 pound weight loss within 30 days. The following interventions were initiated; finger foods with every meal, whole milk with breakfast and dinner, banana and a hard boiled egg with breakfast. A vitals record report indicated Resident 64's weight was 128 pounds on 10/11/18 and was 120 pounds with a BMI of 25.08 on 10/17/18, indicating a severe weight loss of 6.25% in 6 days. There was no documentation indicating Resident 64's weight loss had been reported to the Registered Dietitian, or that it had been discussed by the Nutrition at Risk (NAR) team prior to 10/25/18. The Registered Dietitian (RD) was interviewed on 2/11/19 at 3:58 P.M. During the interview the RD indicated she should have been notified of Resident 64's significant weight loss of 6.25% in 6 days and she had not been. The Certified Dietary Manager (CDM) was interviewed on 2/12/19 at 2:45 P.M. During the interview the CDM indicated she would notify the RD if a resident had a significant weight loss. She also indicated she had not notified the RD of Resident 64's significant weight loss of 6.25% in 6 days. The Director of Nursing Services (DNS) was interviewed on 2/13/19 at 2:56 P.M. During the interview the DNS indicated there was no further information indicating Resident 64's weight loss had been discussed by the NAR team prior to 10/25/18. The facility's Registered Dietitian policy was requested from the DNS on 2/12/19 at 1:25 P.M. A facility RD policy was not provided. 3.1-46

Based on interview, and record review, the facility failed to follow physician orders [REDACTED]. Findings include: On 10/18/18 at 8:31 A.M., Resident C's record was reviewed. [DIAGNOSES REDACTED]. A Plan of Care, with a start date of 7/10/15 and updated 10/16/18, indicated the resident exhibited paranoia and delusions as evidenced by thinking that other people had eaten her food and taken her personal care items. She had a [DIAGNOSES REDACTED]. The goal was that she would easily be redirected with staff interventions. Interventions were to offer reassurance that her belonging were safe, provide 1:1 attention and talk with resident, change the topic of conversation to something happy or tell her a joke, and offer resident replacements for personal care items as appropriate. A Physician order, with a start date of 3/26/18 and discontinue date of 9/15/18, was for [MEDICATION NAME] solution; 100 mg/ml (milligrams per milliliter); administer 175 mg/1.75 ml intramuscularly once a day on Saturdays every 3 weeks for paranoid [MEDICAL CONDITION]. An MAR (Medication Administration Record) for (MONTH) (YEAR) indicated [MEDICATION NAME] was administered as ordered on [DATE]. [MEDICATION NAME] was scheduled to be given next on 8/25/18. The MAR indicated [REDACTED]. An MAR for (MONTH) (YEAR) indicated [MEDICATION NAME] was scheduled to be given on 9/15/18 and then discontinued. The MAR indicated [REDACTED]. A Physician order, with a start date of 9/16/18, was for [MEDICATION NAME] solution; 100 mg/ml (milligrams per milliliter); administer 175 mg/1.75 ml intramuscularly once a day on Saturdays every 3 weeks for paranoid [MEDICAL CONDITION]. The MAR for (MONTH) (YEAR) indicated [MEDICATION NAME] was scheduled and administered on 9/22/18. Review of physician orders [REDACTED]. Behavior Symptom Monthly Summary Forms indicated Resident C was monitored for behaviors of paranoia and delusions. The forms indicated the number of times these behaviors occurred each month. The behaviors of paranoia and delusions occurred in the following months: (MONTH) (YEAR)-2 behaviors; (MONTH) (YEAR)-3 behaviors; (MONTH) (YEAR)-4 behaviors; (MONTH) (YEAR)-4 behaviors; (MONTH) (YEAR)-5 behaviors; and (MONTH) (YEAR)-10 episodes of paranoia and delusional behaviors occurred. On 10/18/18 at 11:40 A.M., the DNS (Director of Nursing Services) was interviewed. During the interview, she indicated Resident C did not receive her scheduled doses of [MEDICATION NAME], as ordered. The DNS indicated the resident should have received [MEDICATION NAME] solution; 100 mg/ml (milligrams per milliliter); administer 175 mg/1.75 ml intramuscularly on 8/25/18 and 9/15/18. This Federal tag relates to Complaint IN 527. 3.1-35(g)(2)

Based on interview and record review, the facility failed to update a care plan for 1 of 3 residents reviewed for care plans in sample of 3. (Resident #Z) Findings include: Resident #Z's clinical record was reviewed on 8-26-2015 at 1:26 PM. Resident #Z's [DIAGNOSES REDACTED]. A review of Resident #Z's care plan entitled ADL (Activities of Daily Living) Assistance dated 8-5-2015 indicated Resident #Z should be encouraged to complete ADL'S per self. A review of Resident #Z's Significant Change MDS (Minimum Data Set) dated 8-5-2015 indicated Resident #Z required extensive physical assist of one person to complete hygiene. In an interview on 8-26-2015 at 2:18 PM, RN #1 indicated the care plan should have been updated. This Federal tag relates to Complaint IN 762. 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to follow physician orders [REDACTED]. (Resident #Z) Findings include: 1. Resident #Z's clinical record was reviewed on 8-26-2015 at 1:26 PM. Resident #Z's [DIAGNOSES REDACTED]. During an observation on 8-25-2015 at 1:59 PM, Resident Z was observed to have a dressing to the right and left lower legs close to the knee. RN #3 removed the following dressings; Kerlix, and a 2 x 3 inch non adherent pad. The skin tears beneath the dressings were observed, and LPN #4 came in to replace the dressings. A physician's orders [REDACTED].#Z's skin tears as follows: cleanse wound, apply [MEDICATION NAME] to wound bed, cover with ABD pad, and secure with Kerlix daily. In an interview on 8-26-2015 at 2:18 PM, RN #3 indicated Resident Z's wounds should have been dressed according to the physician's orders [REDACTED].>2. During an observation on 8-25-2015, at 1:26 PM, Resident #Z was observed to be resting in bed. Prevalon boots were on. During an observation on 8-26-2015 at 10:01 AM, Resident #Z was observed in bed with Prevalon boots on. A physician's orders [REDACTED].#Z was to have Prevalon boots applied only when up in BRODA chair. In an interview on 8-26-2105 at 2:18 PM, RN #3 indicated Resident #Z's boots should have been off when Resident #Z was in bed. This Federal tag relates to Complaint IN 762. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure treatments for fragile skin were completed as ordered for 1 of 3 residents reviewed with treatment orders in a sample of 3. (Resident #Z) Findings include: 1. An observation of a dressing change on 8-25-2015 at 1:59 PM, indicated Resident Z had a dressing to the right and left lower legs close to the knee. RN #3 removed the following dressings: Kerlix, and a 2 x 3 inch non adherent pad. The skin tears beneath the dressings were observed, and LPN #4 came in to replace the dressings over the skin tears. Resident #Z's clinical record was reviewed on 8-26-2015 at 1:26 PM. Resident #Z's [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#Z's skin tears as follows: cleanse wound, apply [MEDICATION NAME] to wound bed, cover with ABD pad, and secure with Kerlix daily. Resident #Z's Care Plan dated 8-5-2015 entitled fragile skin indicated to treat skin tears per physician orders. In an interview on 8-26-2015 at 2:18 PM, RN #3 indicated Resident Z's wounds should have been dressed according to the physician's orders [REDACTED].>2. During an observation on 8-25-2015, at 1:26 PM, Resident #Z was observed to be resting in bed. Prevalon boots were on. During an observation on 8-26-2015 at 10:01 AM, Resident #Z was observed in bed with Prevalon boots on. A physician's orders [REDACTED].#Z was to have Prevalon boots applied only when up in a BRODA chair. Resident #Z's Care Plan dated 8-5-2015 entitled skin risk breakdown indicated Resident #Z should have Prevalon boots on when out of bed. In an interview on 8-26-2105 at 2:18 PM, RN #3 indicated Resident #Z's boots should not have been on when Resident #Z was in bed. This Federal tag relates to Complaint IN 762. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure personal hygiene was completed for 2 of 3 residents reviewed for personal hygiene in sample of 3. (Resident #Z and Resident #A) Findings include: 1. Resident #Z's clinical record was reviewed on 8-26-2015 at 1:26 PM. Resident #Z's [DIAGNOSES REDACTED]. In an observation on 8-25-2015 at 1:26 PM, Resident #Z was observed in bed, and the resident's hair was not combed, giving the resident a disheveled appearance. In an observation on 8-26-2105 at 9:08 AM, Resident #Z was observed up in the BRODA chair in room, and the resident's hair was not combed, giving the resident a disheveled appearance. A review of Resident #Z's Significant Change MDS (Minimum Data Set) dated 8-5-2015 indicated Resident #Z required extensive physical assist of one person to complete personal hygiene and activities of daily living. In an interview on 8-26-2015 at 2:18 PM, LPN #2 indicated Resident #Z's hair should have been combed. 2. Resident #A's record was reviewed 8-26-2015 at 2:21 PM. Resident #A's [DIAGNOSES REDACTED]. During an observation on 8-25-2015 at 2:41 PM, Resident #A was observed to have several days facial hair growth. During an observation on 8-26-2015 at 9:12 AM, Resident #A was observed to have several days facial hair growth. A review of Resident #A's Significant Change MDS (Minimum Data Set) dated 8-22-2015 indicated Resident #A required extensive physical assist of one person to complete personal hygiene and activities of daily living. During an initial round on 8-25-2015 at 2:41 PM, Resident #A was identified as Alert, oriented, and interviewable. In an interview on 8-25-2015 at 3:10 PM, Resident #A indicated he didn't get shaved as often as he would like because there was not enough staff on duty. In an interview on 8-26-2015 at 1:01 PM, CNA #5 indicated through the week, there were enough CNAs to get personal hygiene completed for residents requiring assistance, but on the weekends, especially on second shift there were not enough staff to complete personal hygiene as it should be completed for the residents. This Federal tag relates to Complaint IN 762. 3.1-38(a)(3)(E)

Based on interview and record review, the facility failed to notify the family of a medication change for 1 of 3 residents reviewed for family notification in sample of 7 (Resident #G) Findings include: Resident #G's record was reviewed 6-25-2015 at 10:18 AM. Resident #G's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order included a notation the order was taken on 5-21-2015 at 12:57 PM. Additionally, the order indicated the family was notified of the new order on 5-21-2015 at 12:57 PM. A physician's orders [REDACTED]. The order included a notation the family was notified of the new order on 5-21-2015 at 12:57 PM. The same notation from the previous [MEDICATION NAME] order. In an interview on 6-22-2015 at 11:35 AM, Resident #G's family member indicated the facility had not notified them of the medication order or the increase in dosage. A review of Nurse's progress notes did indicate the family had been notified of the original order but not of the increase in the medication dosage. In an interview on 6-25-2015 at 11:08 AM, RN #1 indicated the family should have been notified of new physician orders [REDACTED]. This Federal tag is related to Complaint IN 111. 3.1-5(b)(1)

Based on observation, record review, and interview, the facility failed to ensure clothing was changed daily for 2 of 3 residents reviewed for clothing changes in a sample of 7. (Resident #E and Resident #G) Findings include: 1. Resident #E's record was reviewed 6-24-2015 at 2:26 PM. Resident #E's [DIAGNOSES REDACTED]. During an observation on 6-22-2015 at 9:10 AM, Resident #E was up in the wheelchair, dressed on a beige blouse with blue circles, and green colored slacks. During an observation on 6-23-2015 at 1:12 PM, Resident #E was observed in a wheel chair. Resident #E had the same beige blouse on with blue circles, and green colored slacks on. A review of Resident #E's care plan did not indicate Resident #E resisted having clothing changed. 2. Resident #G's record was reviewed 6-25-2015 at 10:18 AM. Resident #G's [DIAGNOSES REDACTED]. During an observation on 6-22-2015 at 11:33 AM, Resident #G was observed to have on a gray colored T-shirt with a yellow sports logo and khaki multi pocket shorts. During an observation on 6-23-2015 at 8:45 AM, Resident #G was observed to have on the same gray colored T-shirt with a yellow sports logo and khaki multi pocket shorts. During an observation on 6-24-2015 at 9:48 AM, Resident #G was observed to have on the same gray colored T-shirt with a yellow sports logo and khaki multi pocket shorts. A review of Resident #G's care plans did not indicate Resident #G refused to have clothing changed. In an interview on 6-24-2015 at 3:05 PM, RN #2 indicated the staff were to be sure clothing was different daily, however, if the same staff were not on duty, they may not have know the outfit the resident had worn the day prior. A review of staffing for Resident #G on 6-22, 6-23, and 6-24-2015 indicated CNA #3 worked all three days, and CNA #4 worked on 6-22, and 6-24. In an interview on 6-24-2015 at 3:00 PM, CNA #3 indicated laundry brings clothing back quickly through the day, but usually not quickly enough to get the same outfit on a person 2 days in a row. Further, CNA #3 indicated resident clothing should be changed daily. This Federal tag is related to Complaint IN 111 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure toenails were kept at a comfortable length for 1 of three residents reviewed for toenail hygiene in a sample of 7. (Resident #G) Findings include: Resident #G's record was reviewed 6-25-2015 at 10:18 AM. Resident #G's [DIAGNOSES REDACTED]. During an observation on 6-22-2015 at 11:33 AM, Resident #G's toenails were observed to be long and curled over the end of the toes. Further, Resident #G's family member was clipping the toenails. A review of Resident #G's Care plans did not indicate when Resident #G was to receive toenail care. In an interview on 6-22-2015 at 11:35 AM, Resident #G's family member indicated the facility had been asked to keep Resident #G's toenails clipped. In an interview on 6-23-2015 at 8:53 AM, RN #5 indicated residents were to have their nails clipped by the Podiatrist, or with showers as needed. This federal tag is related to Complaint IN 111 3.1-37(a)