Every finding on record at Goodwill Mennonite Home, Inc.

Based on observation, interview and record review it was determined that the facility failed to 1) monitor cooling temperatures for hazardous meats, 2) monitor tray line hot food temperatures, and 3) ensure that staff wore hair coverings and beard restraints. This was evident during the Kitchen task investigation during the recertification survey and has the potential to effect all residents.The findings include: 1) On 6/08/26 at 9:49 AM the initial kitchen tour was conducted. The observation was done with the facility kitchen manager, Staff #4, and included an interview with him. Freezer #5 contained 8 turkey breasts stored with the plastic covering open. Staff #4 said the turkey breasts were cooked this morning and then put in the freezer to cool. When asked for the cooling log for the turkey breasts, he said the cooling temp was not documented for the turkey breasts. On 6/10/26 at 2:33 PM Staff #4 provided a copy of the facility policy titled Dietary Policies, Procedures, and Organization. A review of the policy revealed a statement under the section Chilling that stated, in part, that warm/hot foods should be placed in a clean, shallow container, uncovered in the refrigerator to cool faster. 2) On 6/10/26 at 2:55 PM an interview was conducted with Staff #4 to request copies of tray line temperature logs for May 2026 through June 10, 2026 lunch service. On 6/10/2026 at 3:40 PM a review of the facility's tray line temperature logs for May was conducted and revealed missing temperatures for hot foods for the lunch service on 6/06/26, 6/09/26, and dinner service on 6/06/26, and missing temperature logs for 5/5/26 - 5/08/26. No breakfast service tray line temperature logs were provided for any of the days requested. On 6/11/26 at 11:10 AM an interview was conducted with Staff #4 to review the finding that the temperature logs were missing temperatures for some cooked/hot foods, and some days had no temperature logs at all and he confirmed the deficiency. On 6/11/26 at 12:21 PM an observation of lunch tray line service was conducted. The observation was conducted with Staff #4 present. When asked to produce the tray line temperature log, the review revealed that staff failed to monitor the temperature for all hot foods being served. 3.) On 6/11/26 at 12:21 PM an observation of the kitchen was conducted. A dietary aide, Staff #14, was observed in the food preparation area without a hair covering or beard restraint. When interviewed, Staff #14 said he had just finished preparing French toast sticks for the next day's breakfast and he was observed to place foil wrap over a tray. The surveyor noted that he did not have a hair covering or beard restraint and he confirmed the fact. Staff #4 who was present was asked if Staff #14 should have his hair and beard covered and Staff #4 said yes. In another area of the kitchen, another dietary aide, Staff #13 was observed as he walked past the tray line service area to the dry good storage area. Staff #13 had a baseball cap style hat on with hair that protruded below the cap by several inches. No hair restraint was observed to be worn. Staff #4, who was present during the observation, was interviewed and asked if all of Staff #13's hair should be covered and the Staff #4 said yes. On 6/11/26 at 12:25 PM an interview was conducted with the Nursing Home Administrator (NHA) to review the deficient practices observed during the kitchen observation and review of temperature logs and policies. with failure of staff to wear hair and beard restraint and the failure to monitor today's lunch tray line food temps The NHA acknowledged the deficient practice and said they would be corrected.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure that a resident requiring assistance with self-care was groomed in a manner that preserved the resident's dignity. This was evident for one (Resident #5) of one resident reviewed for dignity. The findings include:. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. During an observation on 6/9/26 at 11:49 AM, Resident #5 was seated in a wheelchair at the bedside with a cup of cranberry juice in front of him/her. The Resident stated that he/she could not help himself/herself independently, attempted to drink the juice, and spilled it onto his/her shirt and pants.A subsequent observation on 6/9/26 at 12:53 PM showed that Resident #5 continued to sit by his/her bedside, and his/her shirt and pants remained wet. In a later observation on 6/9/26 at 1:26 PM, Staff #15, a nursing assistant, was observed leaving the resident's room with the resident's lunch tray because the resident did not want to eat. The resident was yelling for his/her clothes to be changed; however, Staff #15 continued to leave the room. A record review for Resident #5 included a note from the resident's attending provider indicating that the resident had multiple rheumatoid arthritis deformities, including in the fingers (rheumatoid arthritis is a condition in which the immune system mistakenly attacks the joints, such as the knees or fingers, causing soreness, swelling, and irreversible joint damage). The review also included an MDS assessment dated [DATE] for Resident #5. The MDS noted that Resident #5 was entirely dependent on staff for most self-care needs, including personal hygiene. During an interview on 6/9/26 at 1:31 PM, Staff #8, a licensed practical nurse, was in Resident #5's room with the surveyor. Staff #8 confirmed that the resident's pants and shirt were wet and needed to be changed.

Based on interviews and record reviews, it was determined that the facility failed to develop and implement comprehensive, resident-centered care plans. This was evident for one (Resident #86) of one resident reviewed for vision/hearing. The findings include: A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Staff use care plans to provide resident-centered care that includes support, services, and resources to address residents' needs. In an interview on 6/8/26 at 11:40 AM, Resident #86 was asked about hearing and reported difficulty hearing in both ears, especially the right ear. The resident also noted that she/he sometimes used bilateral hearing aids. In a subsequent interview on 6/10/26 at 12:54 PM with Resident #86, in the presence of Staff #8, a licensed practical nurse, the Resident reported that she/he preferred not to wear the hearing aids at times. A record review for Resident #86 included an admit screener dated 4/27/26, which noted that the resident had minimal hearing difficulty and used hearing aids in both ears. However, further review of Resident #86's comprehensive care plan failed to show that his/her hearing difficulty was addressed or that he/she sometimes preferred not to wear both hearing aids. During an interview on 6/10/26 at 1:02 PM, Staff #16, a registered nurse, confirmed that Resident #86's comprehensive care plan failed to address his/her hearing difficulty and refusal to wear his/her hearing aids. Staff #16 indicated she would update the resident's care plan to reflect that information after the surveyor's intervention.

Based on a record review, observations, and interviews, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received the necessary assistance with eating/drinking. This was evident in one (Resident #5) of two residents reviewed for ADL. The findings include: A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Staff use care plans to provide resident-centered care that includes support, services, and resources to address residents' needs. A record review for Resident #5 on 6/8/26 at 10:20 AM included an admission nutrition assessment noting that Resident #5 required assistance with feeding. The continued review included a care plan initiated on 3/24/26 for Resident #5, stating that the resident was malnourished and at risk for further nutrition decline related to factors such as poor intake. One of the interventions in the care plan, initiated on 3/30/26 and revised on 4/27/26, noted that Resident #5 be given Ensure drinks with meals daily. A follow-up record review for Resident #5 included occupational therapy (OT) treatment encounter notes from 3/21/26 to 4/16/26, which indicated that the resident only drinks Ensure and needed encouragement to increase intake. The review noted that Resident #5 completed a simple drinking task from a can and straw with [minimal] assistance and that a double-handled cup was to be trialed to improve grasp and independence. Further review of the OT discharge summary indicated that Resident #5 required partial or moderate assistance with eating. An observation of Resident #5 on 6/8/26 at 1:12 PM showed the resident in bed and awake, with the head of the bed elevated and an open Ensure drink on the bedside table in front of the resident. The resident pointed to the drink and indicated that staff had left it there for the resident to drink, however, the resident could not drink it independently. In a later observation on 6/9/26 at 11:49 AM, Resident #5 was seated in a wheelchair at the bedside with a cup of cranberry juice in front of him/her. The resident stated that he/she could not help himself/herself independently, attempted to drink the juice, and spilled it on his/her shirt and pants. During an interview on 6/8/26 at 1:13 PM, Staff #17, a nursing assistant, was asked about the level of assistance Resident #5 required for self-care. Staff #17 reported that the resident was totally dependent on staff for all self-care needs. Staff #17 was asked about Resident #5's Ensure drink, which had been left on the table for the resident to drink independently. Staff #17 stated she was unsure who left the Ensure drink there and then assisted the resident in drinking it after the surveyor's intervention. A subsequent interview on 6/10/26 at 10:05 AM with Staff #18, the Director of Rehab, showed that Resident #5 was to be assisted with eating and drinking because his/her grasp was poor and holding on to objects was difficult.

Based on interviews, record reviews, and observations, it was determined that the facility failed to monitor for side effects of blood thinning medication and ensure that the necessary care and services were provided to allow a resident to maintain their highest practicable physical well-being by failing to ensure that a hand splint was supported by a valid physician's order outlining specific parameters for use, skin monitoring, and safety. This was evident for one (Resident #9) of one reviewed for anticoagulant (blood thinner) use and for one (Resident #13) of two reviewed for position and mobility. The findings include: 1) Resident #9 has atrial fibrillation (AFib), which is an irregular, rapid heart rhythm where the heart's upper chambers quiver instead of pumping smoothly, causing blood to pool. Taking a prescribed blood thinner is essential because it prevents these dangerous clots from forming. Anticoagulants are classified as high-risk, high-alert medications due to their potential to cause severe, life-threatening adverse drug events if left unmanaged. Long-term care (LTC) facilities bear a responsibility to establish strict monitoring protocols for any resident on a blood thinner. Because these drugs actively prevent clotting, unmonitored residents face risks of uncontrolled bleeding. On 6/08/26 at 10:59 AM, the surveyor conducted an interview with Resident #9, who informed the surveyor that they are prescribed a blood thinner. On 6/09/26 at 3:01 PM, the surveyor conducted a record review and confirmed that the resident is prescribed Eliquis Oral Tablet 2.5 MG (Apixaban). The order is directed to give 1 tablet by mouth two times a day related to AFib. Further review failed to reveal interventions to monitor for side effects of the blood thinning medication. On 6/09/26 at 3:16 PM, the surveyor conducted an interview with the facility Director of Nursing (DON) and asked what type of interventions would be expected for a resident who takes blood thinning medications. She stated, For blood thinners, we enter an order to monitor for risk of bleeding and add it to geriatric nursing assistant (GNA) tasks so that they can monitor as well. The surveyor then asked the DON to review the orders for Resident #9. The DON confirmed that the resident is prescribed a blood thinner and that the interventions had been missed in the resident's orders. She stated that she would reach out to the physician for orders to monitor for side effects and ensure that they are also included in the GNA tasks. 2) Resident #13 has quadriplegia, meaning they are paralyzed in all four limbs and the torso. They also have contractures of the hands, which is a permanent tightening of the muscles and presents risk for further loss of range of motion, skin breakdown, and severe pain without proper splinting or restorative care. On 6/08/26 at 12:00 PM, the surveyor interviewed Resident #13 and observed a splint placed on the bedside table. When asked, the resident stated that they are supposed to have it on but because it is their bath day, they had not applied it yet. The surveyor noted that the resident's hands were noticeably contracted and rigidity was present in their body. The surveyor asked how often they wear it, and they stated, Most the time. On 6/09/26 at 3:35 PM, the surveyor conducted a record review of the resident's orders and was unable to find any mention of the splint. On 6/09/2026 at 3:42 PM, the surveyor conducted an interview with the Director of Nursing (DON) and asked if there should be an order if a resident has a splint. She replied, Yes, there should be. The surveyor asked her to look at Resident #13's orders, and the DON confirmed that she found no mention of the splint. She also checked the geriatric nursing assistants' (GNAs) tasks and did not see that interventions had been entered for monitoring or placement of the splint. She stated that the resident was currently undergoing Occupational Therapy (OT) and it was possible the splint was being trialed, adding that even splint trials would require an order. On 6/10/26 at 11:41 AM, the DON followed up with the surveyor to report that while the splint is included in the resident's Hospice care plan, it was not addressed in the facility. She reported, It is a family preference to have the splint applied and hospice has been doing it as family wants. The surveyor asked if it would still be the expectation that if a resident has a splint, it should be reviewed by the resident's physician and the facility, and she stated, Yes, it should have been included. During the interview, the DON acknowledged that an order is necessary for splint application and stated it is critical for the GNAs to understand they must follow physician orders rather than individual preferences without an authorization. The DON also stated that a skin assessment should be implemented whenever a brace is utilized to ensure skin integrity is maintained and affirmed that the facility would address the issue immediately.

Based on observation, interview and record review it was determined that the facility failed to use wheelchair footrests when transporting residents by wheelchair. This was evident for one random observation of Resident #99 during the annual survey.The findings include: Resident #99 was admitted to the facility in 2023 with diagnoses that included, but were not limited to, dementia and difficulty walking. On 6/11/26 at 9:43 AM a random observation was conducted of the hallway near the entrance to the North Hall unit, adjacent to the nurses station. An activity aide, Staff #7 was observed as she pushed Resident #99 in a wheelchair that had no footrests attached. The resident's foot got caught on the carpet and the resident yelled out, and said that they could not hold their feet up. Staff #7 paused for a moment, asked the resident if they were okay, and then proceeded to push the resident forward again. No adjustments were made to the wheelchair or the resident. The surveyor then intervened to ask Staff #7 if the resident had footrests for their wheelchair and the activity aide said they did, but they were in the resident's room. Staff #7 then went to the resident's room and returned with footrests and applied them to the wheelchair. The resident's Licensed Practical Nurse (LPN#8) was also present in the hallway and was asked if the resident should have had footrests on their wheelchair. LPN #8 said that although the resident could self-propel in their wheelchair, footrests should be used when the resident was pushed by staff for a long distance. LPN #8 then went to assess the resident. Several other residents were observed in the hallway as they were pushed by other staff in wheelchairs without footrests. On 6/11/26 at 9:51 AM an interview was conducted with the Director of Nursing (DON) regarding the observation that Resident #99 was observed as they were pushed down the hall by Staff #7 without footrests on their wheelchair and the observation that the resident's foot caught on the carpet. When asked how activities staff were trained to transport residents, the DON said that the Activity's Director was responsible for training activity staff. The DON further explained that resident care plans contained the intervention to use wheelchair footrests for long distances, but said that the activities staff did not have access to the nursing care plan. On 6/11/26 at 10:17 AM an interview was conducted with the Activities Director (Staff #9). When asked how activities staff knew which resident's needed footrests, Staff #9 said that the activity assistant should have checked with nursing staff or herself. When asked, she said that there were no written reports or directions on when footrests should be used, and that only verbal explanations were given when needed. A request was made for the facility's policy on transporting residents in wheelchairs. On 6/11/26 at 1:11 PM in an interview with the facility social worker, Staff #11, she relayed the information that the facility did not have a policy regarding transporting residents in wheelchairs. On 6/11/26 at 1:12 PM an interview was conducted with the facility's nursing staff educator, Staff #12 who said she did not train activities staff, only nursing staff. Staff #12 provided an orientation checklist for Staff #7. A review of the document revealed that on 7/14/25 [Staff #9] trained Staff #7 on the safe transport of residents. When asked for Staff #9's credentials, Staff #12 said that Staff #9 used to be a Geriatric Nursing Assistant (GNA) but was no longer licensed as a GNA and was not licensed as a GNA in July 2025 when she trained Staff #7.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure residents were free from significant medication errors. This was evident for one (Resident #66) of four residents observed during the medication administration observation. The findings include: On 6/10/26 at 8:31 AM, the Licensed Practical Nurse (Nurse #10) was observed for medication administration. Nurse #10 gave Resident #66 all his/her medications and assisted in giving the resident a drink. However, the resident spit one pill out and reported that it was too big and asked if it could be crushed. Nurse #10 picked up the pill, verified on the computer what medication it was and stated to the surveyor, It's the Potassium. He then got a new pill from the resident's supply, crushed the medication and mixed it with applesauce. He then went back to the resident's room, administered the medication with a spoon and gave the resident a drink to wash it down. A review of Resident #66's medical orders was conducted on 6/10/26 at 9:14 AM. The review revealed the order for Potassium Chloride Extended-Release tablet. There was no other order for Potassium found in the resident's medical record. Furthermore, an order with a start date of 5/27/22 read, I prefer to NOT have my medications crushed and/or mixed. The surveyor attempted to discuss the findings with Nurse #10 however he was observed to be on break with other staff on 6/10/26 at 10:49 AM. On 6/10/26 at 11:06 AM, Nurse #10 was back in his unit and was interviewed about Resident #66. He stated, yeah I shouldn't have done that. (referred to crushing the extended-release Potassium chloride tablet). He also reported that it was his first time to crush that medication for the resident and explained that when residents have complaints with taking a medication, the usual process was to report the concern to the provider and see if another form (liquid form) can be ordered, if the medication can be crushed, or if the medication was scored then he would cut it in half. According to the Institute for Safe Medication Practices (ISMP) guidance, crushing, breaking, or chewing extended-release pills can destroy their delivery mechanisms, alter dosing, and cause severe adverse events. Crushing destroys the time-release mechanism, resulting in a dangerous, potentially fatal dose being dumped into your system all at once. Crushing Potassium Chloride extended-release tablet destroys the time-release mechanism, dumping the entire dose into your system at once, which can cause severe throat and stomach irritation, or dangerous, life-threatening heart rhythm issues On 6/10/26 at 11:15 AM, Resident #66 was observed moving around the unit in a wheelchair asking what time lunch would be delivered. Further review of Resident #66's medical record was conducted on 6/10/26 at 11:37 AM. The review revealed no documentation to indicate that the resident had been assessed after the medication error or that it had been reported to anyone. A subsequent interview with Nurse #10 was conducted on 6/10/26 at 11:57 AM. He reported that a medical provider was in the facility and that he was waiting on her to make her way to his unit to report the error. The concern of a significant medication error (crushing of the extended-release Potassium chloride tablet) was discussed with the Director of Nursing (DON) on 6/10/26 at 11:57 AM. The DON confirmed that the medication should not have been crushed and that an incident report should have been done immediately.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure expired medications were discarded. This was evident for 1 of 2 medication carts inspected during the recertification survey. The findings include:On 6/9/26 at 2:12 PM, an inspection of the medication cart assigned to Nurse #6 was conducted. During the inspection, an inhaler for Resident #20 had an open date of 4/7/26. Instruction on manufacturers box where the inhaler was kept, indicated that the inhaler must be discarded 1 month after removing from the foil pouch, or whenever the dose counter reads zero, whichever comes first. Nurse #6 confirmed that she administered the morning dose of the inhaler to the resident on 6/9/26 and stated, It's something that we didn't catch. The finding of the expired inhaler was discussed with the Director of Nursing (DON) on 6/10/26 at 12:56 PM. The DON reported that she was already aware of the concern and that the nursing staff had 2 open inhalers for Resident #20 and had used up the newer one first. The DON acknowledged the concern.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that residents had access to a call bell within reach. This was evident for one (Resident #32) of one resident reviewed while completing the environmental task.The findings include: Resident #32 has quadriplegia, which is paralysis affecting the torso and all four limbs. Additionally, the resident has a communication deficit, resulting in significant difficulty speaking or expressing needs. A joint contracture happens when the soft tissues around a joint—like muscles, tendons, or skin—become tight, short, and stiff, locking the joint into a bent or frozen position that prevents normal movement. On 6/08/26 at 10:55 AM, during the initial screening process, the surveyor observed Resident #32 seated in a bedside geri-chair (recliner-type chair). The chair was positioned parallel to the resident's bed, and the call bell had been placed on the bed. The resident was noted to have contracted hands and a contracted torso. Based on the distance between the resident and the bed, as well as the resident's physical limitations, the call bell appeared to be beyond the resident's reach. The surveyor attempted to ask the resident if they could reach the call bell; however, the resident was unable to answer. On 6/08/26 at 11:09 AM, the surveyor was walking past Resident #32's room and noticed that the geri-chair had been moved farther away from the bed. The surveyor entered the room and observed that the call bell remained on the bed. The chair was positioned far enough from the bed that the resident would have had no way to reach the call bell. The surveyor noted that the resident's arms remained contracted toward the body and that the resident was still unable to speak when asked if they could reach the call bell. The surveyor identified a staff member outside the room who identified herself as Geriatric Nursing Assistant (GNA #5). The surveyor asked about Resident #32's call bell, and GNA #5 stated, the resident can't utilize the call bell which is why it doesn't matter if it is near them. When asked whether there was documentation in the resident's care plan indicating that a call bell was not required, GNA #5 stated that she wasn't sure and reiterated that the resident required total assistance and would be unable to use a call bell independently. On 6/09/26 at 11:01 AM, the surveyor conducted a record review of Resident #32's care plan and discovered the following: -Encourage [Resident #32] to use bell to call for assistance- Keep call bell and personal items within easy reach. On 6/09/26 at 2:02 PM, the surveyor conducted an interview with the Director of Nursing (DON) and asked about the facility's expectation regarding resident access to call bells. The DON stated, The expectation is that all residents have a call bell in place. The surveyor informed the DON of the observations in which Resident #32's call bell was not within reach and that GNA #5 had reported that call bell access was not necessary for the resident. The DON stated that GNA #5 should know better and confirmed that it is the facility's expectation that all residents are provided with access to a call bell.

Based on interviews and record reviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for one (Resident #86) of one resident reviewed for vision/hearing. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to collect information on each Resident's strengths and needs. The information collected informs resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the care they need. In an interview on 6/8/26 at 11:40 AM, Resident #86 reported difficulty hearing and noted that she/he sometimes used bilateral hearing aids. A record review for Resident #86 included an admission screener dated 4/27/26, which indicated that the resident had minimal hearing difficulty and wore hearing aids in both ears. Further review of Resident #86's admission MDS assessment dated [DATE] showed that Section B recorded the resident's hearing as adequate, with no difficulty. During an interview on 6/10/26 at 1:02 PM with Staff #16, an MDS nurse, she confirmed that Resident #86's hearing difficulty was not noted in the resident's admission MDS dated [DATE]. Staff #16 added that the MDS assessment would be corrected.

Based on interviews and record reviews, it was determined that the facility failed to have an effective system in place to prevent cognitively impaired residents from leaving the facility without appropriate supervision. This was evident for 1 of 3 residents (#102) reviewed for elopement. This deficient practice led to immediate jeopardy for Resident #102 on 11/13/24. Following the incident, the facility implemented effective and thorough corrective measures. The facility's plan and action were verified during this survey; therefore, this deficiency was cited as past noncompliance. The date of correction was 11/13/24. The findings include: Dementia is a term that describes a group of symptoms associated with a decline in memory or other thinking skills. Brief Interview for Mental Status. The BIMS test is used to evaluate cognitive impairment. A BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance. In an interview on 4/4/25 at 8:30 AM, staff #10, Unit Manager for the Memory Lane Unit, reported that Resident #102 had eloped in the past. A medical record review on 4/4/25 at 10:53 AM showed that Resident #102 had resided in the facility since November 2024. Resident #102 was ambulatory and confused due to the diagnosis of Dementia (Dementia is a general term for impaired ability to remember, think, or make decisions). A review of staff #6, the social services director ' s clinical documentation dated 11/8/24, revealed that due to wandering behavior and diagnosis of dementia, Resident #102 was no longer safe to live at home. Continued review of an Elopement evaluation dated 11/8/24 documented that Resident #102 was a wanderer and had a history of elopement or attempted elopement while at home (A wanderer is someone who roams from place to place, often without a fixed route or purpose. An elopement is when a resident leaves the facility unsupervised). Further record review revealed a Baseline care plan (A baseline care plan is a document outlining initial instructions for providing care to a resident in a long-term care facility developed within 48 hours of admission) initiated on 11/8/24 that stated Resident #102 was a wanderer. However, the review failed to show what interventions were implemented to monitor the resident. Further review revealed a physician certification of medical condition and competency /incompetency form completed on 11/9/24 by two attending providers that indicated that Resident #102 could not understand any information to make informed decisions. Resident #102's medical record review included a nurse's note that had documented that Resident #102 was found outside the facility by housekeeping staff on 11/13/24. A review of the facility's investigation of Resident #102's elopement showed that the resident had followed another resident's family out of the exit door at the end of the Memory Lane C Hallway to the outside of the building at approximately 2:16 PM. Resident #102 traveled down a steep hill from the exit door to the parking lot, which was also near a public road, and across the road was a large pond down another steep hill. An interview on 4/4/25 at approximately 11:00 AM with the director of nursing indicated that Resident #102 had been outside the building for approximately 10 minutes without any supervision on 11/13/24. A corrective action plan was developed and started on 11/13/24 after the incident occurred: a) 15-minute elopement checks were initiated on 11/13/2024 and completed by the nursing staff on 12/3/24 for Resident #102. b) The nursing staff initiated door safety checks every 2 hours on 11/13/24 and completed them on 12/6/24 to ensure all doors at the end of Memory Lanes A, B, and C hallways were closed and latched properly. c) All doors at the end of the hallways of Memory Lane A, B, and C were checked by maintenance on 11/13/24 to ensure that the doors were locked and latched. d) Staff was notified via message and email on 11/13/24 at 4:19 PM to utilize the main entrance doors to enter the Memory Lane Unit and not the exit doors at the end of the Hallways. e) Family members were notified via email on 11/13/24 at 4:25 PM to utilize the main entrance doors and not the exit doors at the end of Hallways A, B, and C into the Memory Lane unit. f) Signage was placed on all the doors at the end of the Hallways of Memory Lane A, B, and C to use the main entrance doors on 11/13/24. g) On 11/13/24, a care plan with interventions to prevent elopement for Resident #102 was initiated. h) An air tag (an Air Tag is a tracking device designed to act as a finder, which helps people find personal objects such as keys, bags, apparel, small electronic devices, and vehicles) was placed on Resident #102 ' s wrist on 12/31/24 to help the staff know the resident ' s location per time. On 4/4/25, a review of credible evidence, including elopement checks, door safety checks, staff and family notifications, and interviews with multiple staff, showed that the facility had identified this deficient practice and implemented interventions to prevent a recurrence. The date of compliance was determined to be 11/13/24.

Based on observations, staff interviews, and a review of facility documentation, it was determined that the facility failed to store controlled substances in a double-locked system and did not maintain proper medication storage temperatures. This was evident for three of three secured medication rooms and three of three medication refrigerators observed for medication storage. The findings include: On 4/10/25 at 10:21 AM, the surveyor observed the medication storage room in the Memory Care unit with Nurse #19. A storage box containing various medications was on top of the medication cart, with drawers sealed by red or green zip ties. Nurse #19 explained that the box holds facility stock (interim) medications: green ties indicate unopened drawers, and red ties indicate opened ones. The surveyor noted that the interim box included Ativan 0.5 mg and Phenobarbital 16.2 mg. Phenobarbital and Ativan are Schedule IV drugs. The facility's Controlled Drug Policy dated 4/8/25, stated: A secured area is one that is kept under two locks; and Schedule II-V controlled drugs must be stored in a locked drawer, separate from all other medications. On 4/10/25 at 10:34 AM, the surveyor observed the medication room in the South Wing with Nurse #21. The same type of stock medication box was present, sealed with red and green zip ties. Drawers were labeled Ativan and Phenobarbital. When asked if these medications were secured, Nurse #21 referred to the zip ties. He stated that two signatures are required when removing medications, but no daily counts are performed. The inventory is managed by the pharmacy during restocking. On 4/10/25 at 10:39 AM, the surveyor observed the medication storage room on the North Unit with Nurse #20. The same type of storage box with green zip-tied drawers was present. When asked about the process for using stock medications, Nurse #20 explained they use a carbon copy logbook and sign out medications with a second nurse. She stated that no daily count is performed; instead, they document each use in the logbook, switch the zip tie to red, and notify the pharmacy. The surveyor observed drawers containing Ativan and another drawer storing Phenobarbital, Ultram, and Xanax together, and the nurse confirmed that they are not included in the daily controlled substances count but that the pharmacy is responsible for tracking the quantities. According to the Drug Enforcement Administration (DEA), Ativan, Phenobarbital, Ultram, and Xanax are all considered Schedule IV drugs. On 4/10/25 at 1:05 PM, the surveyor discussed concerns with the Director of Nursing regarding the controlled substances within the stock medication drawers not being secured with a lock or included in the daily controlled substances count. The Director confirmed that controlled substances should be locked and included in the daily counts. 2.) On 4/08/25 at 11:07 AM, the surveyor observed the secured medication storage room in the South Wing with Nurse #19. The surveyor asked about the facility's process for monitoring refrigerator temperatures. Nurse #19 explained that the night shift maintains the temperature logs and showed the surveyor a log posted next to the refrigerator. When asked about the current temperature, Nurse #19 stated it was 32 degrees. The surveyor then asked what would be done if the temperature was out of range. Nurse #19 replied that she would inform the Director of Nursing (DON). When asked if the current temperature was a concern, Nurse #19 referred to the refrigerator's log instructions, which state, If temperatures are not within the 34 to 44 degree range, promptly notify the DON and the Director of Environmental Services (DES). She confirmed that she should notify the DON. On 4/08/25 at 11:31 AM, the surveyor observed the secured medication room in the Memory Care unit with Nurse #11. When asked about the process for checking refrigerator temperatures, she stated that the night shift is responsible. Upon checking, she reported the current temperature was between 33 and 34 degrees. When asked what she would do if the temperature was out of range, she responded that she would tell maintenance. On 4/08/25 at 11:49 AM, the surveyor observed the secured medication room in the North Wing with Nurse #20. When asked about the current refrigerator temperature, she stated it was between 32 to 33 degrees. The surveyor observed a box of Trulicity stored on a shelf and asked about the manufacturer's storage instructions. After reading the box, Nurse #20 confirmed it should be stored between 36 to 46 degrees. When asked what action she should take, she responded, Call maintenance. On 4/08/25 at 12:04 PM, the surveyor reviewed the medication refrigerator temperature logs for the North Hall and Memory Lane units. The North Hall log instructs staff to notify the DON and DES if the temperature falls outside the 34 to 44°F range. On 3/15/25, the temperature was recorded at 32°F. The Memory Lane log instructs notification if the temperature is outside the 34 to 41 degree range. The following dates had temperatures below the acceptable range: 3/27/25 - 32°F 4/01/25 - 33°F 4/02/25 - 33°F 4/05/25 - 33°F On 4/08/25 at 2:03 PM, the surveyor spoke with the Assistant Director of Nursing (ADON #8) to share concerns about the medication refrigerator temperatures. The surveyor noted that insulin was not being stored according to manufacturer instructions, which require a range of 36 to 46 degrees, yet the facility's guidelines state that refrigerators should be maintained between 34 to 44 degrees. On 4/09/25 at 6:37 PM, the surveyor reviewed the facility's Insulin Storage policy dated 4/8/25. The policy states that both insulin bottles and pens should be stored in the refrigerator but does not specify the required storage temperature. The surveyor observed that insulin was stored in the facility refrigerators. On 4/10/25 at 1:05 PM, the surveyor discussed concerns with the Director of Nursing (DON) regarding the facility's failure to store medications at appropriate temperatures. The surveyor noted that the posted temperature guidelines in each medication room did not align with the manufacturer's instructions for insulin storage. The DON acknowledged that the temperature range guidelines, on the logs currently being used by staff, do not reflect the correct storage temperature range.

Based on review of medical records and facility investigation documentation and interviews it was determined that the facility failed to follow requirements for reporting incidents to the State Survey Agency. This was found to be evident for 5 (Resident #30, # 76, #60, #26, and #160 ) out of 5 residents reviewed for potential abuse. The findings include: 1) Review of Resident #30's medical record on 4/8/25 revealed the resident has a diagnosis of Alzheimer's dementia with severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident had a current order, in effect since 7/31/24, for 2 staff to provide care at all times. The resident also had a current order, in effect since 8/13/24, for the use of a Stander with assist of 2 for transfers. On 4/9/25 review a progress note, dated 3/26/25 at 6:24 AM, revealed that the geriatric nursing assistant (GNA) reported several bruises to the the resident's legs and one to the resident's wrist. The bruises to the legs included: right inner kneecap bruise of 3 X 2 cm; right outer kneecap is 3.5 x 3.0 cm; right lower knee is 1 x 1cm; right shin is 1.3 X 1cm; left upper shin bruise is 5 x 3 cm and left lower shin bruise is 8 x 4 cm; and the left outer wrist bruise was 1.3 X 1 cm. The progress note also indicated the bruises to the legs line up with the stander lift and the discoloration to the left wrist lines up with the dining room table. No documentation was found in the medical record to indicate the resident had sustained a recent fall or other incident to account for the appearance of the six bruises on 3/26/25. The survey agency did not have a facility reported incident report related to Resident #30 for 2025. On 4/9/25 at 6:36 PM surveyor discussed the bruises with the Assistant Director of Nursing (ADON) #8 who reported there may be additional documentation contained in the risk management report and indicated she would provide the report for review. Surveyor then reviewed the concern that the survey agency did not have a facility report related to the bruises. On 4/10/25 review of the risk management report revealed the resident was unable to give a description regarding the bruising. On 4/10/25 01:13 PM the Surveyor reviewed with the Director of Nursing the concern regarding failure to report the multiple bruises to the state survey and certification office. As of time of survey exit on 4/11/25 at 12:15 PM no documentation was provided to indicate these injuries were reported to the state survey and certification office. 45139 2) 4/3/25 at 9:00 AM Resident # 76's, a long-term resident of the facility, medical records were reviewed. The review revealed a note dated 3/12/2025 documenting that Resident #76 had a new purple blue in color skin issue. However, there was no documentation on what caused the skin issue. On 4/07/25 at 11:25 AM the Assistant Director of Nursing ADON, (Staff #10) provided an Incident report for the above injury. On 4/7/25 at 11:30 AM a review of the incident report revealed the conclusion of the investigation was that Resident #76 bumped hip when transferring to wheelchair. In addition, the incident report documented that Resident #76 was verbally reminded to be cautious when going to the wheelchair. Continued review of the incident report failed to determine how the injury happened. On 4/09/25 11:31 AM a review of MDS annual Review dated 11/17/2024 indicated that Resident #76 was unable to transfer her/his self from the bed to the wheelchair or from the wheelchair to the toilet without substantial help from the staff. On 4/10/25 at 8:41 AM geriatric nursing assistant (Staff #26) was interviewed. During the interview she reported Resident #76 and is unable to transfer her/himself from the bed to the wheelchair or the wheelchair to the toilet without staff assistance. On 4/7/25 at 11:54 AM The ADON staff #10 reported that she was responsible for investigating all injuries. She reported that injuries of unknown origin are not reported to the State Agency if she could find a reasonable explanation for the injury. She reported that she did not need to collaborate evidence or statements to determine the origin of the injury. On 4/10/25 at 11:57 AM The Social Service Coordinator (Staff #6) was interviewed. Staff #6 reported that she is responsible for submitting all reportable injuries to the appropriate state agency. She confirmed that she did not report the injury of Resident #76. In addition, she reported that the facility did not submit any reports to the appropriate state agency during the years of 2023 and 2024. On 4/10/25 at 1:33 PM the above concerns were discussed with the Director of Nursing (DON). No additional information was provided. 48470 3) Resident #60 had been residing in the facility since 2021. The investigation packet of a facility reported incident (FRI) related to MD00216040, regarding an allegation of abuse, was reviewed on 4/7/25 at 9:43 AM. The incident alleged that Geriatric Nursing Assistant (GNA #14) had pinched Resident #60 while providing care. Further review of the investigation packet revealed that the incident was first reported to Licensed practical Nurse (LPN #24) on 3/23/25 at 12:19 PM, who then reported to the facility's abuse coordinator (Staff #6) on 3/23/25 at 12:20 PM. The review also stated that the initial report was sent to the state survey agency on 3/24/25 at 4:03 PM. Staff #6 was interviewed on 4/7/25 at 1:22 PM. During the interview, Staff #6 reported her process when an allegation of abuse is made including reporting to the state survey agency immediately but no later than 2 hours. Staff #6 acknowledged that the FRI related to MD00216040 was reported late. She indicated that when she read the instructions on the initial report, she informed the facility and confirmed that they were late in reporting and stated, I informed our facility that we were negligent in reporting the incident. On 4/7/25 at 4:26 PM, the facility's abuse policy was reviewed and indicated that all allegations of abuse should be reported immediately but no later than two hours to law enforcement, Office of Health Care Quality (OHCQ), and Ombudsman. On 4/10/25 at 10:18 AM, the concern was discussed with the Director of Nursing (DON). The DON reported that she was already aware that the facility was late to report the incident of abuse related to MD00216040. 51900 4a) Resident #26 has a history of dementia [impaired memory, language, and problem solving] and physical impairments requiring staff to provide total assistance when moving the resident and providing daily care. On 4/7/25 at approximately 11:00 AM, Surveyor review of Resident #26's skin evaluation assessment note dated 12/7/24 revealed that the resident had acquired an injury as noted: Location: Right eyelid. Issue type: Bruising. Wound acquired in-house. Wound is new. Length (cm): 1, Width (cm): 0.5. On 4/08/25 at 10:00 AM the surveyor reviewed the investigation report dated 12/7/24, which revealed: Nursing description: 1cm x 1 cm light blue discoloration noted to the right lateral eye upper lid. There was no record of the facility reporting the incident to the state regulatory agency. 4b) Resident #160 was admitted to the facility on [DATE] for care related to dementia. The surveyor reviewed complaint MD00195657 which expressed concern that Resident #160 had multiple bruises. On 4/08/25 at 2:15 PM, surveyor review of Resident #160's medical record revealed the following: On 7/6/23, 7/18/23, and 7/20/23, administrative progress notes stated that Resident #160 had bruises. On 7/24/23- Nursing Note- Geriatric Nursing Assistant notified this nurse during morning care of a bruised area to the top of left foot and under 2nd 3rd and 4th toes, bruise bluish purple in color, 4.5cm x 2.0cm. On 8/4/23: Nursing Note: Noted deep purple bruise to right foot/toes, 3x2cm. On 4/8/25 at 10:00 AM, the surveyor was provided with copies of two injury investigation reports for Resident #160. One was dated 7/24/23 and the other dated 8/4/23. There was no record of the facility reporting the incidents to the state regulatory agency. On 4/08/25 at 1:00 PM, the surveyor reviewed the facility policy and procedure titled Abuse Policy dated March 2025 which stated that All alleged incidents of verbal, sexual, physical, and mental abuse; neglect, crime, injury of unknown source; and misappropriation of resident property shall immediately be reported to the Director of Nursing (DON) and the Administrator. The DON will promptly report the alleged abuse to the Social Services Coordinator who is responsible for ensuring that the incident is reported within the appropriate time frame of discovery as listed below: - Serious Bodily Injury or Abuse-reported within 2 hours (to law enforcement, Office of Health Care Quality, and to the Ombudsman. - All others within 24 hours. The facility policy doesn't reflect the state regulation that requires that all injuries of unknown origin are reported within two hours. On 4/08/25 at 4:15 PM, the surveyor interviewed Assistant Director of Nursing (ADON #10), who confirmed that she is responsible for investigating unusual events related to resident care. When asked to describe her process for investigating injuries of unknown origin or unexplained bruising, she stated that her approach includes obtaining and reviewing staff statements, performing a resident assessment, conducting a record review, and asking other residents if they saw anything. When specifically asked whether injuries of unknown origin should be reported, ADON #10 responded, I would figure out if it was abuse and report it. However, when the surveyor requested documentation confirming that such incidents had been reported, ADON #10 stated, I haven't done it, because I haven't received a report of an injury of unknown origin. The surveyor then expressed concern that the bruising of unknown origin for Resident's #26 and #160 had not been reported to the appropriate regulatory agency. In response, ADON #10 confirmed that she had no additional documentation related to the incident. On 4/10/25 at 1:05 PM, the surveyor discussed concerns with the Director of Nursing regarding the facility's failure to report injuries of unknown origin. Specifically, the bruising observed on Resident #26 and Resident #160 had not been reported, and the facility's policy did not align with regulatory requirements for reporting such incidents. The Director of Nursing agreed that the bruising should have been reported and acknowledged that the incidents should have been reported within two hours, as required.

Based on review of medical records, facility investigation documentation, and interviews it was determined that the facility failed to ensure injuries of unknown origin were thoroughly investigated. This was found to be evident for 2(Resident #30 and #26) out of 5 residents reviewed for potential abuse. The findings include: 1) Review of Resident #30's medical record on 4/8/25 revealed the resident had a diagnosis of Alzheimer's dementia with severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident had a current order, in effect since 7/31/24, for 2 staff to provide care at all times. The resident also had a current order, in effect since 8/13/24, for the use of a Stander with assist of 2 for transfers. On 4/9/25 review a progress note, dated 3/26/25 at 6:24 AM, revealed that the geriatric nursing assistant (GNA) reported several bruises to the the resident's legs and one to the resident's wrist. The bruises to the legs included: right inner kneecap bruise of 3 X 2 cm; right outer kneecap is 3.5 x 3.0 cm; right lower knee is 1 x 1 cm; right shin is 1.3 X 1 cm; left upper shin bruise is 5 x 3 cm and left lower shin bruise is 8 x 4 cm; and the left outer wrist bruise was 1.3 X 1 cm. The progress note also indicates the bruises to the legs line up with the stander lift and the discoloration to the left wrist lines up with the dining room table. On 4/9/25 at 6:36 PM the Assistant Director of Nursing (ADON #8) indicated there was a risk management report that she would provide for surveyor review regarding the resident bruising. On 4/10/25 review of the risk management report revealed the resident was unable to give a description regarding the bruising. In the section of the report for statements, four staff were listed with the shifts they had worked from 3/24 night shift through 3/25 night shift. The statement from the staff who worked the 3/25 night shift was dated 3/26/25, and consisted of Noticed multiple discolorations while giving care and reported to my nurse. The entirety of the statements, dated 3/28/25, from the three staff that worked with the resident in the three shifts prior to the identification of the bruising consisted of : didn't notice. No documentation was found in this report to indicate that these three staff were asked any questions regarding events that may have contributed to the bruising. Further review of the risk management report revealed the following statements: Areas bumped into stander lift when being transferred; and Resident bumped left wrist on edge of table in dining room producing bruise. On 4/10/25 at 12:26 PM surveyor reviewed the risk management report with the Director of Nursing (DON). When asked how they came to the conclusions about the source of the bruising, the DON stated we would have to ask ADON #10. On 4/10/25 at approximately 12:46 PM interview with ADON #10 revealed the ADON did interview staff, including asking if they had two staff to assist with care. Surveyor reviewed the concern that the investigation documentation provided failed to support that a thorough investigation had been conducted. On 4/10/25 01:13 PM Surveyor reviewed with the Director of Nursing the concern regarding failure to have documentation of a thorough investigation. 51900 2) Resident #26 has a history of dementia [impaired memory, language, and problem solving] and physical impairments requiring staff to provide total assistance when moving the resident and providing daily care. On 4/7/25 at approximately 11:00 AM, Surveyor review of Resident #26's skin evaluation assessment note dated 12/7/24 revealed that the resident had acquired an injury as noted below: Location: Right eyelid. Issue type: Bruising. Wound acquired in-house. Wound is new. Length (cm): 1 Width (cm): 0.5 The note did not indicate how the bruise to the right eyelid occurred. On 4/08/25 at 10:00 AM the surveyor reviewed the investigation report dated 12/7/24, which revealed: *Nursing description: 1cm x 1 cm light blue discoloration noted to the right lateral eye upper lid, probably occurred with transfer with the hoyer lift pad. *According to staff statements, three out of four individuals reported that they did not notice the bruise, while one stated they found and documented it-though no additional details were provided. *The final investigation conclusion dated 1/7/25 written by Assistant Director of Nursing (ADON#10) stated that the bruise was caused by the hoyer lift. On 4/08/25 at 4:15 PM, the surveyor interviewed ADON #10, who confirmed she conducts investigations into unusual events related to resident care. When asked about her process for investigating injuries of unknown origin or unexplained bruising, she stated that her process includes obtaining and reviewing staff statements, performing a resident assessment, conducting a record review, and asking other residents if they saw anything. She then summarized the findings. The surveyor asked if she interviews and assesses other residents in cases of unknown-origin injuries, and she replied, oh, yes. However, when asked for documentation of such investigations, she stated, I haven't done it, because I haven't received a report of an injury of unknown origin. Regarding whether a bruise on the eye is considered normal, she responded, are you talking about Resident #26? and explained she did not work at the facility at the time of the incident; a previous nurse initiated the investigation, but acknowledged she was aware of the incident and that she did complete the final note concerning the investigation about the bruise to the resident's eye. The surveyor then expressed concerns that the investigation failed to include evidence to support how the determination was made that the bruise was caused by the hoyer lift. ADON #10 stated that she had no additional documentation about this incident. On 4/10/25 at 1:05 PM, the surveyor discussed concerns with the Director of Nursing regarding the facility's failure to conduct a thorough investigation for injuries of unknown origin. Specifically, the facility did not document a thorough investigation into the cause of the bruising to Resident #26's right eye. She agreed that the facility needed to do a more in depth investigation. On 4/10/25 at 4:50 PM, Surveyor review of facility Policy and Procedure titled Injuries of Unknown Source revealed the following: An injury should be classified as an injury of an unknown source when all of the following criteria are met: The source of the injury was not observed, the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury. The Procedure section of the policy states that the facility will obtain written statements from any GNAs assigned to the resident and if no cause is evident, the nurse is to attempt two phone calls to each GNA working on the past three shifts, if necessary, to determine the cause of the injury. The nurse will obtain the GNA's statement. Injuries of unknown sources will be tracked by Quality Assurance to determine potential causes and preventions. On 4/10/25 at 5:05 PM, the surveyor interviewed the Quality Assurance Nurse (Staff #15) and asked if incidents involving injuries of unknown origin are discussed in the quality meetings. She stated that ADON #10 does bring concerns, but was unable to provide any additional clarification about any changes that may have been made to prevent future occurrences or improve the investigations related to the incidents.

Based on observations, record review, and interviews, it was determined that the facility failed to 1) document why a Gradual Dose Reduction (GDR) was contraindicated for the use of psychotropic drug and document specific indications for administering the medicine to a resident and 2) adequately monitor residents for behaviors, side effects, or adverse consequences related to the use of psychotropic drugs. This was evident for 3 (#4, #67, and #7) of 6 residents reviewed for unnecessary medications. The findings include: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Gradual Dose Reduction (GDR) is the stepwise tapering of a dose to determine if a lower dose can manage symptoms, conditions, or risks or if the medication can be stopped. 1) In an initial tour of the South A unit on 4/2/25 at 11:22 AM, Resident #4 was observed in a wheelchair sitting in a common area. The resident was sleeping while other residents were participating in an activity program. A record review on 4/8/25 at 8:38 AM contained a monthly pharmacy review note dated 12/5/2024 that revealed that Resident #4 was Started on Seroquel [a psychotropic drug] 12.5mg [twice daily] on 11.20.24 r/t [related to] increased agitation. Further review of an attending physician's order showed that on 11/20/24, Resident #4 started on Seroquel 12.5mg twice daily. The continued review contained a nurse's note dated 12/1/2024 that documented that Resident #4 refused all medications this morning. [S/he] has been sleepy throughout this shift and noted to be napping in [his/her] [wheelchair] or while sitting up in bed. [S/he] has had no abnormal behaviors or wandering. Continues Seroquel. A review of Resident #4's care plan initiated on 8/3/2022 and revised on 1/23/2025 for mood and behavior was completed. One of the interventions on the care plan stated to observe closely for side effects of psychotropic medications, including drowsiness, hallucinations, and fatigue. A review of the facility's policy titled monitoring of antipsychotics presented to the surveyor stated that the effect of pharmacologic, behavioral modifiers are addressed in nursing notes in the resident's chart and the resident's care planning. However, a review of Resident #4's medical record revealed that it lacked continued monitoring of the resident's behaviors before and after starting the drug, as well as side effects. During an interview on 4/8/25 at 9:13 AM, Staff #8, a registered nurse (RN), reported that Resident #4 slept a lot in the mornings and mid-mornings and then woke up by 1:00 PM. Staff #8 continued to state that probably [his/her] medication needs to be tweaked, referring to the resident's psychotropic medicine. In a subsequent interview on 4/8/25 at 12:38 PM, staff #31, a pharmacist, reported that she depended on the staff's documentation, attending provider's notes, and behavior monitoring flow records to determine if a resident was experiencing any adverse effects to help her make recommendations. However, an earlier record review of Resident #4's medical record lacked documentation of continued monitoring of behaviors, side effects, or adverse consequences related to the use of his/her psychotropic drug. After the surveyor's intervention, the facility initiated an order for the nurses to observe Resident #4 closely for side effects of Antipsychotic medication and document every shift. 2a) In an observation on 4/2/25 at 12:10 PM, Resident #67 was sitting in the wheelchair by the bedside and sleeping. The resident's representative was present in his/her room and reported, Sometimes [s/he] sleeps a lot; I don't know why. A subsequent observation on 4/3/25 at 10:21 AM showed Resident #67 sitting in a wheelchair by the bedside and sleeping. Staff #32, a geriatric nurse aid (GNA), was present and stated, [s/he] sleeps a lot sometimes in the mornings, [his/her] drugs are hard on [him/her] in the morning. A review on 4/8/25 at 3:06 PM showed that Resident #67 had been residing in the facility since 2022. A continued review of Resident #67's attending physician's orders revealed an order for Seroquel 37.5 mg twice daily for Dementia with other behaviors. The review also showed a pharmacy monthly medication regimen review (MMR) report dated 4/05/23 with a recommendation for Resident #67's attending physician to review the resident's use of Depakote and Seroquel for a GDR. The attending physician signed the recommendation on 4/11/23 with a response: Stable for now. Will start Depakote GDR next month. Further review found another MMR report dated 10/5/23 that recorded that GDR was declined in April when the pharmacy asked. Noted at that time a GDR would be started in May on Depakote. I do not see any changes made, please review. Resident #67's attending physician responded that the resident has been quite stable on this regimen, No [changes] at this time. The review failed to show that Resident #67's use of Seroquel was addressed with a clinical rationale by the physician of why an attempted reduction for the drug should not be attempted. The physician also failed to follow up on his written statement that he would GDR the Depakote. A continued review of an order summary report as of 4/9/25 revealed that Resident #67 continued to receive Seroquel twice daily for Dementia with other behaviors. However, a review of Resident #67's attending physician's note failed to give a specific indication of why the resident was getting the medicine and whether a GDR had been attempted since the medication was ordered again in January 2024. In an interview on 4/10/25 at 9:15 AM, the director of nursing (DON) said that a GDR should be attempted yearly after the first year of use of psychotropic medication. The DON also added that Resident #67 was not followed by the facility's Psychiatric group but was managed by attending Physician #28 for all his/her psychiatric needs. After checking the attending physician's notes, the DON confirmed that it lacked documentation of GDR attempts. In an interview on 4/10/25 at 1:14 PM, attending physician #28 confirmed that his notes did not show attempted GDR after the first year of Resident #67 using the antipsychotic medication and stated he would improve on his documentation. The attending physician was also made aware of the concern of not documenting the specific indication for the continued need for the antipsychotic medication for Resident #67. 2b) Psychotropic drug is defined as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. Resident #7 was admitted to the facility in 2024 with diagnosis that includes depression, anxiety and psychotic disorder. On 4/3/25 at 12:17 PM, a review of Resident #7's medical orders were conducted. The review revealed that the resident was on anti-psychotics, anti-anxiety and anti-depressants. On 4/3/25 at 12:50 PM, a review of Resident #7's electronic Medication Administration Record (eMAR) for the month of March 2025 was conducted. The review confirmed the medications that the president was taking under the classification of anti-psychotic, anti-anxiety, and anti-depressant. However, there was no documentation to indicate that the facility was monitoring its use and side effects. On 4/7/25 at 3:17 PM, the Director of Nursing (DON) was interviewed about the use and monitoring of psychotropic medications. The DON reported that she had not seen orders to monitor and document side effects from the use of psychotropic medications and indicated that there were behavior sheets that the nursing staff documents on and should have an area for documenting side effects. The DON also reported that this document is filled out by hand and is then scanned into the resident's chart. A review of Resident #7's electronic health record on 4/7/25 at 3:25, revealed the latest scanned behavior monitoring sheet. The document was done for the month of January 2025 and was titled Behavior/Intervention monthly flow record. The upper right corner of the document indicated that this was to be used for anti-anxiety, anti-depressant, anti-psychotic, sedative/hypnotic medications; and the lower right portion of the form listed the potential side effects from numbers 1 to 28, where number 28 was none or no side effects. The nursing staff had documented daily on the number of behavior episodes. However, out of the 31 days reviewed, the nursing staff had documented 1 day for side effects. On a subsequent interview with the DON on 4/7/25 at 3:50 PM, the concern was discussed, and she indicated that she reviewed Resident #7's medical record and confirmed that there was no order to document and monitor the side effects from the use of psychotropic medications. She also confirmed that the behavior sheet scanned in the resident's record was mostly blank for side effects. The DON stated, I'm surprised our pharmacist hadn't identified that. Further review of Resident #7' medical records on 4/8/25 at 10:49 AM, revealed new orders starting on 4/7/25 at 11:00 PM, to observe closely for significant side effects for anti-anxiety, anti-depressant, and anti-psychotic medication every shift.

Based on observations and interviews, it was determined that the facility failed to ensure that holes were repaired in drywall. This was evident for two of the two bathrooms reviewed for the facility environment. The findings include: On 4/2/2025 at approximately 11:00 AM, the surveyor observed a gap in the drywall near the pipe beneath the bathroom sink shared by residents in rooms [ROOM NUMBERS]. A few minutes later, a similar gap was noted in the drywall beneath the sink in the bathroom for room [ROOM NUMBER]. Additionally, in room [ROOM NUMBER]'s bathroom, the plate covering the area where the pipe from the toilet enters the wall had come loose, exposing a gap in the drywall. On 4/08/2025 at 10:58 AM, the surveyor interviewed the Environmental Services Director (ESD #17). When asked about the process for addressing areas in need of repair, ESD #17 explained that maintenance staff regularly walk the facility to identify necessary repairs and that housekeepers or other staff members also report issues as they arise. The surveyor informed ESD #17 about the gaps observed in the residents' bathroom areas. In response, he stated that someone would be sent to inspect the issue. On 4/08/2025 at 11:06 AM, the surveyor noted that there had not been repairs to the wall around the pipes in the shared bathroom between rooms [ROOM NUMBERS]. On 04/10/25 at 1:05 PM, the surveyor discussed concerns with the Director of Nursing regarding the failure to identify gaps around the pipes beneath the sinks, as well as the loose plate on the resident's toilet.

Based on record reviews and interviews, it was determined that the facility failed to ensure residents were protected from abuse. This was evident for 1 (Resident #60) of 5 residents reviewed for abuse. The findings include: Resident #60 was admitted to the facility in 2021. The investigation packet for an abuse allegation on the resident, related to MD00216040 was reviewed on 4/7/25 at 9:43 AM. The review revealed that a Geriatric Nursing Assistant (GNA #14) had pinched Resident #60. The facility's Abuse Coordinator was the Social Services Coordinator (Staff #6). Staff #6 was interviewed on 4/7/25 at 1:22 PM. During the interview, Staff #6 reported that abuse was substantiated after the facility's investigation. Staff #6 indicated that the facility was able to substantiate abuse due to reports by GNA #18, who was also providing care to Resident #60 at the time of the allegation. On 4/7/25 at 2:37 PM, the Chief Human Resources Officer (Staff #13) provided documentation to indicate that GNA #14's employment was terminated on 3/27/25. Furthermore, GNA #14 was banned from coming into the vicinity of the facility and from contacting other employees and/or residents. Staff #13 also provided documentation to indicate that GNA #14's abuse allegation was reported to the Maryland Board of Nursing. On 4/10/25 at 10:18 AM, the Director of Nursing (DON) was interviewed. During the interview, the concern was discussed that the facility had failed to protect Resident #60 from abuse. The DON verbalized understanding and acknowledged the concern.

Based on record review and staff interview, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days for a resident admitted to hospice care. This was evident for 1 (Resident #80), who was reviewed for hospice. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected on the MDS drives Resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The nursing home should complete a Significant Change in Status MDS assessment within 14 days when there's a major decline or improvement in a resident's status. A record review on 4/3/25 at 10:36 AM showed that Resident #80 had resided in the facility since May 2023. A review of Resident #80's current attending provider's orders showed that the Resident was admitted to hospice care effective 1/22/25. The continued review contained a Significant Change in Status MDS assessment dated [DATE] for Resident #80. The MDS assessment was completed and signed in sections Z0500B & V0200B2 on 2/19/25, 29 days after admission to hospice care and 15 days late. During an interview on 4/9/25 at 3:18 PM, staff #22, the MDS coordinator, indicated that she was unaware of the time frame for completing a Significant Change in Status MDS assessment after a resident was admitted to hospice care. Staff #22 confirmed that Resident #80's Significant Change in Status MDS assessment dated [DATE] was completed late.

Based on record review and interview, it was determined that the facility failed to accurately reflect Resident #107's discharge plan on the Minimum Data Set (MDS) assessment. This was evident for one out of one resident reviewed for discharge planning. The findings include: A Minimum Data Set (MDS) is a standardized assessment tool that helps to evaluate the health status of residents in long-term care facilities. The information gathered helps facilities to develop patient centered care plans based on the resident's unique needs. On 4/9/25 review of the Resident 107's progress notes revealed the following: A review of the care plan dated 1/27/25 indicates that Resident #107 wishes to be discharged to their home. On 1/29/25 - Nursing Note: Resident #107's representative visited and inquired about their return to their apartment. Resident representative was informed that we would consult with Physical Therapy (PT) to assess their progress. PT later reported s/he is doing very well-independent in their room via wheelchair-and has also been performing well during sessions in their assisted living apartment. On 1/30/25 - Social Services Note: Received notification from Humana that the resident's skilled stay will end on Saturday, 2/1/25. Discharge to their assisted living apartment is planned for Sunday, 2/2/25. The resident's family member was notified and are aware of the discharge plan. On 1/31/25 - Restorative Program Note: Resident's therapy was scheduled to end today; no restorative care is planned at this time. Therapy provided a home exercise program in preparation for discharge to assisted living on Sunday, 2/2/25. Further review of the medical record revealed in Section A of the 2/2/25 MDS that the resident intended to discharge with a return to the facility anticipated. On 4/09/25 at 3:28 PM, the surveyor interviewed the facility's MDS Coordinator (Staff #22), who confirmed that she is responsible for completing Section A of the MDS assessment. The surveyor asked how she determines how to answer Section A, Question F. Staff #22 explained that it depends on the residents and their expressed wishes for discharge. The surveyor then asked her to review Resident #107's MDS assessment dated [DATE], where Section A, Question F was marked as Discharge assessment - return anticipated. The surveyor questioned this choice, noting that both the progress notes and care plan indicated the resident planned to return to their apartment in an assisted living setting. Upon reviewing the MDS assessment again, Staff #22 acknowledged that she should have selected return not anticipated because the resident intended to return to their assisted living apartment. She added that although return not anticipated was the appropriate response in this case, she often chooses return anticipated for residents who frequently return to the facility.

Based on record review and interviews, it was determined that the facility staff failed to develop a person-centered baseline care plan that included interventions for monitoring a resident who was identified as an elopement risk. This was evident for 1 (#102) of 9 residents reviewed for accidents. The findings include: A baseline care plan is a document outlining initial instructions for providing care to a resident in a long-term care facility, developed within 48 hours of admission. A record review on 4/4/25 at 10:53 AM, showed that Resident #102 was admitted to the facility in November 2024 with diagnosis including Dementia (Dementia is a general term for impaired ability to remember, think, or make decisions). The Resident was confused and walked independently. The review also contained an Elopement evaluation completed on 11/8/24 that indicated that Resident #102 was a wanderer and had a history of elopement or attempted elopement while at home (A wanderer is someone who roams from place to place, often without a fixed route or purpose). Continued review of a baseline care plan completed on 11/8/24 for Resident #102 showed that the resident was a wanderer. However, the review failed to show what staff did to monitor him/her. Further review included a nurse's note dated 11/13/24 that stated that Resident #102 was found outside of building by housekeeping staff The resident was assessed at that time and noted to be very confused. In an interview on 4/9/25 at 8:09 AM, staff #25, an MDS coordinator reported that the baseline care plan was expected to document the care needs of residents. During an interview on 4/9/25 at 5:01 PM, staff #22, an MDS coordinator reported that Resident #102 was identified as a wanderer on the baseline care. The staff continued to state that the baseline care plan did not contain any intervention for monitoring Resident #102 because s/he was on the locked unit. However, earlier review showed that the resident was ultimately able to leave the facility unsupervised on 11/13/24, a few days after admission.

Based on medical record review, facility investigation, and staff interviews, it was determined that the facility staff failed to maintain the safety of a totally dependent resident while providing routine care resulting in the resident falling out of bed. This action resulted in a 5 cm(centimeter) hematoma to the right side of the head, abrasions across the back, bruising to the chest, left arm, right arm and the back of the head requiring pain management. This was evident for 1 (#16) of 4 residents reviewed for accidents. The finding included the following: A hematoma is localized swelling that is filled with blood caused by a break in the wall of a blood vessel. The breakage may be spontaneous, as in the case of an aneurysm, or caused by trauma. By way of history, according to the medical record, (resident #16) had End Stage [MEDICAL CONDITION], History of falls, [MEDICAL CONDITIONS], Dysphagia, Abnormal posture, muscle weakness and contracture of the right ankle and foot. The resident was nonverbal and totally dependent on staff for all aspects of care. Review of the medical record on 9/4/18 at 11:56 AM, revealed that, on 10/13/17 at approximately 8:25 PM, GNA #1(Geriatric Nursing Assistant) and GNA #2 were providing incontinence care to Resident #16. GNA #2 went into the bathroom to obtain additional washcloths and wipes. While GNA #2 was retrieving wash cloths and wipes, GNA #1 moved the resident in a way that caused him/her to slide out of the bed onto the floor, hitting his/her head on the side of the bed. This action resulted in a 5 cm(centimeter) hematoma to the right side of the head, abrasions across the back, bruising to the chest, left arm, right arm and the back of the head. Ice was applied to the forehead at the time of the incident. According to a nurse's note, dated 10/14/17 at 2:48 AM, the resident was noted with facial grimacing. PRN Tylenol was given for comfort from the fall. Further review of Resident # 16's medical record on 9/4/18 revealed that the facility staff conducted a Quarterly MDS (Minimum Data Set) assessment and coded Section G 0110 A Bed Mobility as 4/3 (Total dependence with 2-person physical assist). Review of the (MONTH) (YEAR) physician's orders [REDACTED]. During an interview with GNA#1 on 9/5/18 at 2:09 PM, s/he stated the following: I had gloves on. (GNA#2) is over there and I'm here (meaning opposite sides of the bed), one on each side of the resident. I rolled him/her up away from me, one hand on the shoulder and one on the waist. The resident was a big mess and (GNA#2) went to get more washrags and wipes. I already had my hand in it. The resident was coming back towards me, and I started pushing away from him/her and the sheet and everything went. I think s/he fell from the way that I was trying to go up, because I had bent down, and s/he just kept going. The education I got was that I should have only rolled the resident towards me. But my mindset at the time was that I wanted to keep the resident out of the mess we were cleaning up. Review of the facility investigation on 9/6/18 revealed the following: (GNA #2) wrote in a statement dated 10/14/17, I went in to help with resident care. There was a big mess, I went into the bathroom to get more towels and wash cloths. (GNA#1) said in a loud voice, I need help fast. When I came out of the bathroom the resident was on the floor on his/her back. Continued review of the medical record revealed the following: 10/16/17 at 11:07 AM- Left lower extremity [MEDICAL CONDITION] per his/her usual self. Right shoulder, upper right arm and right side of upper neck noted with increased swelling, purple discoloration remains. Facial grimacing and crying out when repositioned by staff. Md notified. New order received to administer [MEDICATION NAME]/APAP 5mg/325mg one by mouth every 4 hours as needed for moderate to severe pain times 14 days. Review of the (MONTH) (YEAR) MAR (Medication Administration Record) failed to reveal that the pain medication was administered on 10/16/18. 10/17/17 at 2:53 pm- Discoloration remains to right side of the head, neck area, and right side of the back of neck. Right shoulder remains swollen. Continues with facial grimacing and crying out when being repositioned by staff. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview with the Director of Nursing on 9/6/18 at 1 PM, he/she stated that GNA (#1) and GNA (# 2) had been in-serviced on the proper positioning of a resident.

Based on a review of the medical record, administrative records, and staff interviews, it was determined that the facility staff 1). failed to adequately supervise and protect a resident from an injury, for 1 of 3 residents reviewed for falls and fractures within 30 days and 2). failed to label and securely store cleaning solutions in 1 of 4 kitchenette areas and 1 tub room.Findings include: 1.Review of administrative records, and the statement written by GNA # 1 on 9/28/2013, revealed that she wheeled resident # 11 into the tub room with her legs dangling. She picked the resident's legs up to position them onto the foot rest, and noticed a red swollen area to outer left ankle. She asked another GNA to get the nurse to look at the resident's ankle. Review of the radiology report for resident # 11 on 9/28/2013 revealed that there appeared to be a nondisplaced fracture of the distal fibula. An interview was conducted with GNA # 1 on 10/23/2013 during which she stated, " I proceeded to push resident # 11 backwards in her chair out of her room and down to the bathing room. Her blanket was over her legs and I did not see her legs hanging off the sides of the chair.Her legs hit against the door as I was pulling her gerichair out of her room " . She further stated, "I take full responsibility for not making sure that her legs were on the chair and not dangling along the sides" . Additionally; GNA # 1 was given a written warning indicating that resident # 11 sustained a major injury as a result of the incident that occurred on 9/28/2013, as she cared for the resident. In conclusion, GNA # 1 failed to properly supervise resident # 11 and protect her from being injured. As a result, resident # 11 suffered a fracture of her left fibula. Residents who are totally dependent on staff for all of their care should be properly supervised, and care and safety should be maintained to ensure that a resident is free from harm and injury. 2).Failed to label and securely store cleaning solutions in 1 of 4 kitchenette areas and 1 tub room. The findings include: On 10/21/2013 at 10:20 AM, during the Initial tour of the facility, the surveyor observed a plastic spray bottle, approximately 1/2 full of a liquid substance, with a manufacturer's label identifying it as NABC concentrate cleaner/disinfectant. The bottle was located in an cabinet under the sink of the North hall kitchenette area, which is in a corner of the North hall day room. The cabinet was not locked, and was easily opened by the surveyor. During an interview on 10/21/2013 at 10:40 AM, Nurse # 4 stated "the cleaner should not be stored under the sink", and removed the cleaner at that time. On 10/21/2013 at 10:50 AM during observation of the North hall bathing room, the surveyor observed 1 plastic spray bottle 3/4 full of yellow/green liquid. The spray bottle was on a shelf next to a large jug labeled shampoo, they were both on a shelf located beside whirlpool tub. the spray bottle had no label or identification as to it's contents. During an interview on 10/21/2013 at 10:50 AM, GNA(Geriatric Nursing Assistant) #4 identified the liquid as Gen clean, and stated that "it is used for cleaning and sanitizing the whirlpool tub". When asked how would someone know what it is, or what it is for?, she stated "it should be labeled". Nurse #5 was made aware of both of the above findings at 10:55 AM, and removed the unlabeled spray bottle from the bathing room. The facility administrator was made aware 10/22/2013 at 4:00 PM. Failure of the facility staff to maintain proper identification and storage of cleaning supplies places the residents at risk for accidents related to accidental misuse.

Based on family and staff interview, observation of the resident, review of the resident's medical record and review of administrative records, the facility failed to prevent the resident from injury in 1 of 26 medical record reviews during the stage 2 survey process. The findings include: Resident # 57 is a [AGE] year old male readmitted to the facility on [DATE]. Past medical history includes a left sided subdural hematoma with VP shunt. The resident, per his attending physician, is incompetent to make decisions related to his care due to recovering from a subdural hematoma. During a family interview via phone on 5/17/09, it was noted during the conversation, that the resident's physical condition had declined due to a fall sustained on 12/26/09. The fall resulted in the resident being transferred to the hospital. The resident sustained [REDACTED]. Due to increased pressure, the hematoma was removed surgically. Surveyor review of the resident's medical record on 5/17/09, after interview with the family, revealed the following nurses note. "Concurrent Review 12/26/09 11:50 pm Resident fell + hit the back of head /c (with) minimal amt. of bleeding. Resident was not moved. Rec'd order to send to (name of hosp.) Fall occurred at 9:20pm. Resident was alert, verbal, able to speak, stated his head hurt, pupils non-reactive." After review of the above nurse's note, the surveyor requested the incident report from the facility staff, as well as any investigation that was conducted at the time, as well as his complete medical record for the month of December 2009. Surveyor review of the resident's clinical status and physician orders [REDACTED]. Physician order [REDACTED]. 1. Personal alarm on for safety per POA request. 2. Bed/Chair confined. 3. Pressure alarm in and out of bed. 4. Low bed fall mats on both sides of bed for safety. 5. Out of bed to w/c with seat belt for positioning. All the orders prescribed above are safety mechanisms used to assist staff to protect the resident from sustaining an injury from a fall. The medical record did not indicate that resident #57 had independently ambulated since his readmission to the facility on [DATE] until his hospitalization on [DATE]. Continued review of the record revealed the resident's Minimum Data Set (MDS).This is a tool that is a federally mandated process for clinical assessment required by nursing homes to be completed for each resident. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. The facility staff develops care plans based on the MDS assessment, past medical history, current clinical status, as well as resident and family input. The MDS signed 12/14/09 by a registered nurse and other treatment team members, reveals that the resident was totally dependent on staff with the assist of one, for personal hygiene and toilet use. Cognitive skills for daily decision making were moderately impaired, that his mental functioning varied over the course of the day, and that he sometimes understood others and responded adequately to simple, direct communication. . As stated above, care plans are put into place to guide a resident's care. Plans and interventions are adjusted as the resident improves, declines, or new physician orders [REDACTED]. The resident had in place, care plans for bowel/bladder incontinence, as well as potential for falls. Interventions for bowel and bladder incontinence was for the staff to, " provide care every 2 hours and as needed-briefs liners to maintain dignity. " A new physicians telephone order, 12/14/09 1030 states, " Prompt toileting every two hours & PRN (as needed) to promote dignity & continence." Revision of the current bowel/bladder incontinence care plans did not include the new physician's orders [REDACTED]. The potential for falls care plan did not address how the resident would be monitored as well. After surveyor review of the medical record, a review of the facility's incident report and investigation revealed: RN#1 and GNA#1 took the resident to the bathroom unlatching the personal alarm from his shoulder. GNA#1 showed the resident how to work the call bell in the bathroom and he demonstrated that he could pull it. Both staff members left the bathroom, and the resident was left unattended. GNA #1 stated that she informed GNA#3 (the resident's primary caregiver for the evening) that he was in the bathroom and would call for assistance when he was finished. The resident's personal alarm was not reattached once in the bathroom. GNA#2 was walking past the resident's room, heard a big bang, turned and saw the resident on the floor. GNA#2 called verbally up the hallway for assistance. RN#1 arrived in the resident's room, assessed the resident whose head was bleeding and stated it hurt. 911 called, the resident transported to the emergency room at approximately 9:30 pm. The call bell was sounding in the bathroom. The resident was admitted to the hospital. During the course of his 21 day stay, it was determined that he initially sustained an acute right subdural hematoma. Surgical intervention was used to remove the hematoma. The resident developed a temperature elevation which required a spinal tap. The test was positive for increased white cells and protein. The resident then was administered a strong course of intravenous antibiotics (vancomycin) to reduce the infection/temperature. He was discharged back to the nursing home on January 15, 2010. Surveyor interview with the facility Director of Nursing Services (DON) on 5/20/10, after review of the medical record, incident report and investigation, revealed that GNA# 3 was not in the resident's room or near the bathroom. GNA#3 was across the hallway tending to another resident. The DON also indicated that she felt the staff should have been at the bathroom door. Surveyor interview on the same date with the facility Administrator and Director of Nursing Services revealed that the resident was left in the bathroom by himself for dignity issues. It was stated that the staff member who was walking past the resident's room (GNA #2) was right there to obtain assistance immediately for the resident once the bang (fall) was heard. Resident #57 was deemed incompetent by his primary physician to make sound decisions due to his current medical condition. The resident, based on the medical record, lacked the cognitive and functional capabilities to protect himself from harm. His past medical history includes a left sided subdural hematoma from a fall which resulted in his admission to the nursing home. Leaving this resident unattended in the bathroom resulted in another fall with injury, hospitalization and surgery. .