Garland Road Nursing & Rehab Center

assessment, dated 07/10/25, showed their cognition was intact with a BIMS score of 14.

The assessment showed the resident was admitted with diagnoses which included acute kidney failure, nontraumatic intracerebral hemorrhage, and type 2 diabetes.Resident #4's nurses notes, dated 09/18/25, read in part, .Late Entry for 09/1825 05:15 AM resident was upset to find another resident in her room going through [her] roommates' closet. 3. On 09/24/25 at 9:35 a.m., Resident #11 was observed lying in bed with head of bed elevated at twenty degrees.

Their call light was in reach, the bed was low, and a fall mat was in place.

The resident only smiles and did not respond to any questions. A facility document titled Incident Case report, dated 07/08/25, read in part, .Resident found in female residents' room [they] had fallen asleep with [their] on [other residents] bed.

Both residents fully clothed.

Resident removed from [gender withheld] residents' bed and took back to [their] own room. PCP, DON, and left voice mail on [family representatives] phone to call back.Resident #11s annual assessment, dated 09/01/25, showed their cognition was significantly impaired and was unable to participate in the BIMS assessment.

The assessment showed Resident #4 was dependent for toileting and hygiene and required supervision or touching assistance for bed mobility.

The assessment showed the resident required partial to moderate assistance with transfers and they used a wheelchair for mobility.

The assessment showed Resident #4 had diagnoses which included type 2 diabetes, pseudobulbar affect, and bradycardia. On 09/23/25 at 2:51 p.m., Resident #4 stated Resident #11 was coming into their room and their closet. Resident #4 stated they requested to be moved rooms to prevent it from happening again and feels safe in the facility. On 09/24/25 at 10:41 a.m., family representative #3 stated they were notified Resident #5 was found lying clothed in Resident #11's bed.

They stated the police were called and the physician has been adjusting resident #5's Seroquel due to the resident becoming increasingly confused in the evening. On 09/24/25 at 11:20 a.m., CNA #2 stated Resident #5 was found lying in Resident #11s bed sleeping fully clothed half on the bed and half on the floor. CNA #2 stated Resident #11's room was changed, the police were called, family was notified, and a report was made. CNA #2 stated Resident #5 continues to go into the same room where Resident #4 is now located. CNA #2 stated that there has been nothing done to prevent Resident #5 from going into other resident's room. On 09/09/25 at 1:30 p.m., RN #1 stated Resident #5 had wandering behaviors which included wandering into other resident rooms. RN #1 stated the intervention to prevent the resident wandering into other residents' room was to redirect the resident. On 09/09/25 at 2:12 p.m., the ADON stated Resident #5 was reported to wander into Resident #11's room and get in their bed and fell asleep.

The ADON stated they moved Resident #11's room. On 09/24/25 at 3:20 p.m., the DON stated Resident #5 has behaviors of wandering in and out of other resident's room.

The DON stated there was an incident on 07/08/25 where Resident #5 was found sleeping in Resident #11's bed with Resident #11.

The DON stated there was another incident recently when Resident #5 wandered into Resident #4's roommates closet.

The DON stated the interdisciplinary team should have met and care planned interventions after each incident of wandering.

The DON stated Resident #5's care plan was not updated with interventions to prevent wandering after 06/20/25. On 09/24/25 at 4:24 p.m., family representative #4 stated they were notified on 07/08/25, Resident #11 was found in bed with Resident #11.

Family representative #4 stated the police were notified, they consented to Resident #11's room being changed, and Resident #11 was not harmed.

On 09/29/25 at 5:15 p.m., corporate nurse # 1 stated the facility did not have a policy for ensuring care plans were revised and reevaluated after an incident.

Corporate nurse #1 states the facility follows the RAI manual.

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