Broadway Creek Senior Living

Based on observation, medical record review, review of the Self-Reported Incident, review of witness statements, review of the incident log, review of nursing staff shift assignments, review of staff time punches, review of the resident admission agreement, review of resident council meeting minutes, policy review, and interview, the facility failed to ensure sufficient nursing staff to provide appropriate safety and supervision to residents residing on the secured memory care unit. This affected one (Resident #65) and had the potential to affect the additional 21 residents (#48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #66, #67, #68 and #69) who resided on the secured memory care unit. The census was 69.

Findings include:

Review of the medical record for Resident #65 revealed an admission date of 05/07/25 with diagnoses of dementia with hallucinations and delusions, psychotic affective disorder, diabetes, atrial fibrillation, and status post myocardial infarction. Resident #65 resided on the secured, memory care unit.

Review of the safety care plan dated 10/29/25 revealed Resident #65 required every two-hour safety checks and to monitor for signs of elopement.

Review of the Change in Condition evaluation dated 01/16/26 revealed Resident #65 was severely cognitively impaired and had a poor attention span. Resident #65 ambulated independently, wandered as a pattern and was goal oriented (going home, looking for someone, etc.) and/or had poor decision-making skills and/or not easily redirected.

Review of the undated Elopement Risk Evaluation revealed Resident #65 was at high risk for elopement.

Review of the observation progress note dated 03/08/26 timed 4:30 P.M. authored by the Health Services Director (HSD) revealed on 03/08/26 at 9:30 A.M., Resident #65 was observed outside lying down on the grass in the memory care courtyard. Resident #65 was alert to person only. Two staff members assisted Resident #65 back into the building and helped the resident into the shower. Resident #65's blood sugar was 468 mg/dL and his temperature was 90.0 degrees Fahrenheit (F). The note indicated staff were unable to obtain any further vitals due to the resident shaking. Emergency Medical Services (EMS) was called and took the resident to the emergency department. The residents Power of Attorney (POA), physician and Executive Director (ED) notified.

Review of the Palcare report (the facility's pager system) revealed a door sensor at an unknown location was activated on 03/08/26 at 4:38 A.M.

Review of the After Visit Summary dated 03/09/26 revealed Resident #65 was admitted to the ICU for close monitoring and a Bair hugger. His temperature had remained in the normal range and did not require Bair hugger after initially getting into the emergency department. The principal problem/diagnosis was hypothermia due to exposure.

Review of the Self-Reported Incident dated 03/08/26 revealed neglect/mistreatment abuse was alleged/suspected when Resident #65 had an unwitnessed fall outside the memory care side door. On 03/08/26 at 10:08 A.M., Resident #65 was observed on the ground outside of the memory care side door in a puddle, in the secured courtyard. Resident #65 was checked for injury and 911 was called and the resident was transported to the hospital for evaluation. The facility substantiated abuse, neglect or misappropriation verified by evidence.

Review of the nursing staff shift assignments for night shift from 03/07/26 into 03/08/26 revealed Certified Medication Aide (CMA) #87 and Resident Assistant (RA) #92 were the only nursing staff in the whole facility to care for 69 residents, 18 residents of which resided in the secured memory care unit. CMA #87 was scheduled to work on 03/07/26 from 6:00 P.M. to 6:00 A.M. on and RA #92 was scheduled to work on 03/07/26 from 10:00 P.M. to 6:00 A.M.

Review of the time punch from 03/07/26 to 03/08/26 for RA #92 revealed RA #92 clocked in at 10:04 P.M. on 03/07/26 and clocked out at 6:08 A.M. on 03/08/26.

Review of the time punch from 03/07/26 to 03/08/26 for CMA #87 revealed CMA #87 clocked in at 10:04 P.M. on 03/07/26, clocked out for lunch at 4:52 A.M. on 03/08/26, clocked back in from lunch at 5:26 A.M. on 03/08/26 then clocked out at 6:25 A.M. on 03/08/26.

Review of the undated witness statement authored by the ED revealed on Sunday, 03/08/26 at 10:08 A.M. the HSD was notified by LPN #88 that Resident #65 was observed on the ground outside of the memory care side door in a puddle. The ED was then notified at 10:17 A.M. Upon investigation, RA #92 was assigned to memory care and CMA #87 was assigned to the assisted living [during night shift from 03/07/26 into 03/08/26]. Resident #65 had returned to the building [from the hospital] around 2:30 A.M. [on 03/08/26]. RA #92's last check on Resident #65 was approximately 4:40 A.M. and the resident was assisted to the bathroom, then back to his recliner. According to the call log, the memory care side door opened at 4:46 A.M.

Review of the elopement witness statement authored by RA #92 dated 03/08/26 revealed Resident #65 arrived back from the hospital anywhere from 1:00 A.M. to 1:30 A.M. [on 03/08/26]... Around 4:00 A.M. to 4:30 A.M., RA #92 started another round of check and changes. Around 4:40 A.M., RA #92 got to Resident #65. Resident #65 was wearing a pair of underwear and shirt, so RA #92 got him a brief and he sat back in his chair around 4:50 A.M. To which RA #92 answered some pagers going off up front [assisted living side of the facility]. RA #92 returned to the memory care unit around 5:00 A.M. to 5:15 A.M.

Review of the elopement witness statement authored by CMA #87 dated 03/08/26 revealed Resident #65 returned from the hospital between 1:00 A.M. and 2:00 A.M. [on 03/08/26]. The RA (unnamed) and CMA #87 made sure the resident was safely put in his bed. It stated we worked short staffed the night of 03/07/26 leading up to the morning in question. At 5:30 A.M., there was a fall and the RA (unnamed) and CMA #87 had to work together to help Resident #13, the note further stated there was nobody in memory care for the time being.

Observation on 03/16/26 at 9:10 A.M. revealed Resident #65 was ambulating independently out of his room into the hallway.

During an interview on 03/16/26 at 2:40 P.M., the ED and HSD verified the memory care unit was left unsupervised on 03/08/26 when RA #92 had to leave the unit to assist CMA #87 when Resident #13 (who resided on the assisted living side of the facility) fell at approximately 5:30 A.M. or 5:45 A.M.

During an interview on 03/16/26 at 2:45 P.M., RA #92 stated Resident #65 had a history of wandering and exit seeking. On 03/07/26 at 10:00 P.M., RA #92 arrived for his first night shift and RA #92 and CMA #87 were the only staff in the entire facility. At approximately midnight, RA #92 did his first rounds on the memory care unit and answered pages from residents on the assisted living, so the memory care was left unsupervised for 30 minutes. At approximately 1:00 A.M., RA #92 reentered the memory care unit to finish the rest of his rounds. At approximately 1:00 A.M. or 1:30 A.M., Resident #65 arrived back from the hospital... At 4:45 A.M. or 4:50 A.M., RA #92 got to Resident #65. After RA #92 was finished with Resident #65, RA #92 received a lot of pages up front (in the assisted living) from Resident #8 and Resident #36 and he exited the memory care unit to assist those residents. CMA #87 had also needed assistance when Resident #13 (in the assisted living) fell and needed urine cleaned up. At approximately 5:20 A.M. or 5:30 A.M., RA #92 returned to the memory care unit to finish rounds.

A follow-up interview on 03/16/26 at 3:40 P.M. with the ED verified CMA #87 and RA #92 were the only staff scheduled for night shift from 10:00 P.M. on 03/07/26 to 6:00 P.M. on 03/08/26. The ED also verified the facility standard was to have three nursing staff members scheduled to work from 10:00 P.M. to 6:00 A.M.

A follow-up interview on 03/18/26 at 5:00 P.M. with the ED verified CMA #87 was on lunch break from 4:52 A.M. to 5:26 A.M. on 03/08/26.

Review of the resident council meeting minutes from 01/13/26 revealed an unnamed resident asked, Do we have 24-hour nursing? Is there a med-tech [CMA] here every night? How many caregivers are here at night? The ED responded by stating, yes we have 24-hour nursing and our med-techs [CMA's] help provide that for overnight. We have three caregivers [RA's] here at night in memory care and one in assisted living.

Review of the facility's Resident Admission Agreement Exhibit 11 regarding Special Populations dated October 2022 revealed it was the purpose of the community to provide a quality living environment to residents who may require assistance with personal care, intermittent nursing, monitoring and supervision, but do not require 24-hour skilled nursing care. The community's ability to meet residents' needs shall be based upon a comprehensive pre-admission assessment of the resident's physical, health and social needs; preference and capacity for self-care. There were three shifts spanning 24 hours, caregivers and licensed nurses would be staffed 24 hours a day.

Review of the facility's Wandering and Elopement Prevention Plan Program policy revised on 07/12/22 revealed the purpose of the policy was to provide a system for identification of residents at risk for unsafe wandering and elopement, provide a program of supervision and interventions to minimize risk to resident elopements and elopement attempts.

This violation represents non-compliance investigated under Master Complaint Number OH00170063 and Complaint Number OH00169949.

Based on medical record review, review of witness statements, policy review, review of the corrective disciplinary form, and interview, the facility failed to ensure medications were administered per physicians order for Resident #65. This affected one (Resident #65) of three residents reviewed for neglect.

Findings include:

Review of the medical record for Resident #65 revealed an admission date of 05/07/25 with diagnoses of dementia with hallucinations and delusions, psychotic affective disorder, diabetes, atrial fibrillation, and status post myocardial infarction. Resident #65 resided on the secured, memory care unit.

Review of the Change in Condition evaluation dated 01/16/26 revealed Resident #65 was severely cognitively impaired and had a poor attention span. Resident #65 ambulated independently, wandered as a pattern and was goal oriented (going home, looking for someone, etc.) and/or had poor decision-making skills and/or not easily redirected.

Review of the physician orders from March 2026 revealed Resident #65 was ordered a blood sugar check before all meals and at bedtime; the blood sugar checks were scheduled for 7:00 A.M., 11:30 A.M., 4:00 P.M. and 8:00 A.M. Resident #65 was ordered to be administered Novolog Flex 100 units/milliliters (a short-acting insulin) five units subcutaneously three times daily before meals which was scheduled for 7:30 A.M., 11:30 A.M. and 4:30 P.M. and to hold for blood sugar less than 150 milligrams/deciliter (mg/dL) (around 70 to 130 mg/dL was the normal target fasting blood sugar level for diabetes). Resident #65 was also ordered Pantoprazole (a medication used to treat gastroesophageal reflux disease) one tablet by mouth one time a day at 6:00 A.M.

Review of the observation progress note dated 03/08/26 timed 4:30 P.M. authored by the Health Services Director (HSD) revealed outside (on premise) on 03/08/26 at 9:30 A.M., Resident #65 was observed outside lying down on the grass in the memory care courtyard. Resident #65 was alert to person only. Two staff members assisted Resident #65 back into the building and helped the resident into the shower. Resident #65's blood sugar was 468 mg/dL and his temperature was 90.0 degrees F. The note indicated staff were unable to obtain any further vitals due to the resident shaking. Emergency Medical Services (EMS) was called and took the resident to the emergency department. POA, physician and ED notified.

Review of the March 2025 Medication Administration Record (MAR) revealed Resident #65's Pantoprazole scheduled for 6:00 A.M. on 03/08/26 was not administered. A MAR exception note dated 03/08/26 timed 11:58 A.M. authored by the Health Service Director (HSD) revealed Resident #65 was on a leave of absence. Resident #65's blood sugar check scheduled for 7:00 A.M. was not recorded until 11:58 A.M. by the HSD. At that time, Resident #65's blood sugar was documented as 548 mg/dL.

Review of the emergency department physician progress note dated 03/08/26 timed 11:28 A.M. revealed Resident #65 with history of dementia, diabetes, hypertension, chronic kidney disease, atrial fibrillation presented to the emergency department after he was found alone, outside. He was unaccounted from around midnight until he came in around 11:00 A.M. EMS noted he was hyperglycemic as well as hypothermic. He did receive five units of insulin prior to arrival. He was unable to provide any history. Clinical impressions noted the resident with hypothermia (low temperature), tachycardia (high heart rate), elevated brain natriuretic peptide (BNP) level (a hormone produced by the heart to diagnose heart failure), altered mental status, elevated lactic acid level (inadequate oxygen delivery to tissue) and hyperglycemia (elevated blood sugar). Vital signs were consistent with hypothermia, and he was placed on the Bair hugger (forced air warming system). Examination and history were as noted above and was very limited as the patient was not answering questions and he was unaccounted for nearly 11 hours at nursing home. The note stated they would administer a small bolus of intravenous fluids. The physician did not believe the patient required an insulin drip for diabetic ketoacidosis (DKA). It stated the Resident #65 would be admitted to the intensive care unit (ICU).

Review of witness statement authored by the Executive Director (ED) revealed a conversation with Licensed Practical Nurse (LPN) #88 on 03/10/26 with the ED and HSD. It stated when asked what LPN #88 did from 6:00 A.M. to 10:00 A.M. on 03/08/26 before the incident, LPN #88 stated that she came in and got report from the CMA (unnamed). After that, LPN #88 input her incident report from the evening before. After that she started her medication pass on the assisted living side of the facility. LPN #88 stated she got pulled for an incident and also pulled by question from other residents before she got back to the memory care unit . LPN #88 stated she got to the memory care unit around 9:30 A.M. At that time, she was looking for Resident #65 to give him his medications. LPN #88 was unable to find him in his room so she alerted the other staff to start looking for him. He was not located in any of the residents rooms or bathrooms. At that point, LPN #88 went outside to look for him. When she got outside the side of the memory care side door was when LPN #88 observed Resident #65 lying on the ground.

Interview on 03/17/26 at 9:10 A.M. with the ED verified LPN #88 did not administer medications as ordered for Resident #65, especially the scheduled insulin for 7:30 A.M. The ED also verified the nurse may have realized Resident #65 was missing sooner if the medications were administered on time on 03/08/26.

Review of the corrective disciplinary form dated 03/20/26 revealed LPN #88 had a medication error when medications were not administered per medication administration policy. LPN #88 signed the form on 03/22/26.

Review of the facility's Medication Management policy revised on 12/19/22 revealed medication assistance would occur according to the prescribed times and methods as indicated by the resident's physician and as indicated on the medication containers label.

This violation represents an example of continued non-compliance.

Based on observation, medical record review, resident admission agreement, review of resident council meeting minutes, and interview, the facility to ensure resident laundry services were completed in a timely manner. This affected two residents (Residents #2 and #34) of three residents reviewed for laundry services. The facility identified all 69 residents received laundry services in the facility.

Findings include:

1. Review of the facility's resident admission agreement dated November 2022 revealed services included in the monthly fee were: laundering of clothing, linens and towels.

Review of the resident council meeting minutes from 01/13/26 revealed an unnamed resident stated, are the aides trained on laundry because it doesn't seem like they are. The ED responded stating, caregivers should be changing your beds on your shower days or assigned laundry day for those who shower independently. We will do a laundry educational and training for care staff.

Interview on 03/16/26 at 10:32 A.M. with Resident Assistant (RA) #86 revealed the RA's were responsible for doing resident laundry and they (the RA's) were always behind on laundry. If there was another RA on shift (three RA's instead of two RA's from 6:00 A.M. to 2:00 P.M.), then the laundry got done.

Interview on 03/16/26 at 10:45 A.M. with RA #85 revealed laundry was not getting done.

Interview on 03/17/26 at 9:10 A.M. with the Executive Director verified resident laundry was not being done in a timely manner.

2. Review of the initial evaluation assessment for Resident #34 dated 09/03/25 revealed the community was responsible for laundry assistance one to two times a week for Resident #34.

Observation on 03/16/26 at 10:05 A.M. revealed Resident #34's laundry hamper was overflowing with dirty clothes. Interview, during the observation, with Resident #34 revealed the RA's were supposed to do laundry on the resident's shower days. Resident #34's most recent shower day was on Saturday (03/14/26) however the RA's did not wash his laundry because there wasn't enough staff that day.

Observation on 03/17/26 at 8:20 A.M. revealed Resident #34's laundry hamper continued to overflow.

3. Review of the semi-annual evaluation assessment for Resident #2 dated 11/26/25 revealed the community was responsible for laundry assistance one to two times a week for Resident #2.

Interview on 03/16/26 at 9:45 A.M. with Licensed Practical Nurse (LPN) #84 revealed the facility didn't have enough staff. Resident Assistants (RA's) were supposed to launder resident's clothes and linens however laundry was not getting done. Resident #2 took his laundry to the laundry mat because staff were unable to do his laundry.

Interview on 03/16/26 at 12:25 A.M. with Anonymous Staff #90 revealed laundry was not getting done so Resident #2 would take his laundry out to a nearby laundry mat.

Interview on 03/17/26 at 8:30 A.M. with Resident #2 revealed the laundry service was not dependable and it was a hit or miss so Resident #2 had to take his laundry to a nearby laundry mat. Resident #2 stated he sat his laundry outside his door on a Wednesday, and the laundry was still there on Friday. The RA's finally picked up the laundry on Friday however it wasn't back at 11:00 P.M. so Resident #2 checked the laundry room where he found his laundry soaking wet in baskets. So Resident #2 put his laundry in the dryer then was folding laundry at midnight.

Based on observation, review of resident council meeting minutes, and interview, the facility failed to provide an independent and natural dining experience when current food menus were not posted. This had the potential to affect all 69 residents who received meals from the kitchen.

Findings include:

Review of the resident council meeting minutes dated 02/10/26 revealed an unnamed resident asked, can you put the menus out? The Culinary Director responded, yes the menus will be posted.

Observation on 03/16/26 at 8:10 A.M. outside the dining room of the assisted living revealed the lunch meal was Shepard's pie and veggie.

Observation on 03/16/26 at 8:40 A.M. revealed there wasn't a daily food menu posted within the secured memory care unit.

Interview on 03/16/26 at 8:20 A.M. with Certified Medication Aide (CMA) #81 verified there wasn't a menu posted on the memory care unit and the menu by the assisted living dining was not always updated so the meals were a surprise.

Interview on 03/16/26 at 8:43 A.M. with Resident Assistant (RA) #82 revealed he wasn't aware what was on the menu for the day because it was whatever the kitchen serves that day.

Interview on 03/16/26 at 9:45 A.M. with LPN #84 revealed the menus were never changed outside the assisted living dining room so staff and residents were consistently asking what was going to be served for lunch and dinner.

Interview on 03/16/26 at 10:05 A.M. with Resident #34 revealed no food menus were posted.

Interview on 03/16/26 at 10:45 A.M. with RA #85 revealed the menu outside the dining room wasn't updated daily and the Shepard's pie menu was from a meal last week.

Interview on 03/16/26 at 11:50 A.M. with Culinary Services Director (CSD) #80 verified she would forget to post the menu by the assisted living dining room, verified the Shepard's pie meal was served on 03/13/26 and verified the posted menu outside the assisted living dining room wasn't updated during the weekend (03/07/26 and 03/08/26).

Interview on 03/16/26 at 12:00 P.M. with the ED verified a food menu was not posted within the secured memory care unit.

Interview on 03/16/26 at 12:25 P.M. with Anonymous Staff #90 revealed the food menu was never correctly posted outside the assisted living dining room.

Interview on 03/16/26 at 2:10 P.M with RA #92 revealed the posted menu wasn't followed. Residents would ask what they were eating that day and RA #92 wouldn't know.

Interview on 03/17/26 at 8:30 A.M. with Resident #2 revealed the food menu was rarely ever posted and if it was posted, it was not correct.

A follow-up interview on 03/17/26 at 9:10 A.M. with the ED verified the posted menu outside the assisted living dining was incorrect.

Interview on 03/23/26 at 9:55 A.M. with Resident #46 revealed the menu wasn't posted and if the menu was posted, it wasn't followed.

This violation represents non-compliance investigated under Complaint Number OH00169949.

Based on observation, record review, review of the facility's Self-Reported Incident (SRI), review of witness statements, review of the facility's pager system report, review of nursing staff shift assignments, review of staff time punches, review of the National Weather Service climatological data, review of the resident admission agreement, policy review, and interview, the facility failed to provide a safe environment and adequate supervision to prevent an elopement.

This resulted in a Real and Present Danger and actual harm on 03/08/26 at 4:38 A.M. when Resident #65, who was severely cognitively impaired, assessed as being high risk for elopement, had a history of wandering and exit seeking behaviors, and resided on the secured memory care unit, exited the facility via a door to the outside enclosed memory care unit courtyard. The memory care unit had been left unsupervised, the security features of the exit doors were malfunctioning and/or disabled, and staff were not utilizing the correct monitoring/paging equipment. Resident #65 was missing for approximately five hours and 30 minutes, where he was found outside the 100-hall exit door, lying on the ground without socks or shoes on, in a water puddle, covered in mud with signs and symptoms of hypothermia. Resident #65 was transferred to the hospital and diagnosed with hypothermia (low temperature) and hyperglycemia (high blood sugar). The temperature outside on the morning of 03/08/26 was approximately 43 degrees Fahrenheit (F). This affected one (Resident #65) of three residents reviewed for supervision and had the potential to affect 16 additional residents who the facility identified as cognitively impaired and independently mobile residing on the secured memory care unit. The facility census was 69.

On 03/17/26 at 2:16 P.M., the Executive Director (ED), Environmental Services Director (ESD) #83, Regional Director of Health Services (RDHS) #93, Regional Director of Operations (RDO) #94 and Vice President of Clinical Operations (VPCO) #95 were notified the Real and Present Danger began on 03/08/26 at 4:38 A.M. when Resident #65 wandered into the outside enclosed courtyard without staff knowledge and was found approximately five hours and 30 minutes later, muddy, wet and cold. Resident #65 was admitted to the hospital with a diagnosis of hyperglycemia and hypothermia from exposure.

The Real and Present Danger was abated on 03/17/26 when the facility implemented the following corrective actions:

On 03/08/26, the ED was educated by RDO #94 and RDHS #93 that there was to be a minimum staffing of two care staff (Resident Assistant [RA])/Certified Medication Aide [CMA]/nurse) on the memory care unit.

Beginning on 03/08/26, the ED and Health Services Director (HSD) withdrew the RA's key to the screamer alarm (an alarm attached to the top inside portion of the door that would alarm locally) on the door, which could be activated and deactivated via a key. A key would only be granted to CMAs, the nurse and administration.

Beginning on 03/09/26, all staff were educated by the ED on the facility's abuse and neglect policy. If phone contact with staff was unsuccessful, staff education would be provided prior to beginning the next scheduled shift by the ED.

Beginning on 03/09/26, all staff were educated by the ED regarding shift report and equipment report, initiated walking rounds, head counts/eyes on all residents specifically in the memory care unit, and to check doors first thing ensure properly alarmed as well as not leaving the memory care unit unsupervised.

Beginning on 03/09/26, RAs, CMAs and nurses were educated by the ED on the facility's Alert Charting policy to ensure that a resident with a change in condition was monitored by nursing per the policy. If phone contact with staff was unsuccessful, staff education would be provided prior to beginning the next scheduled shift by the ED.

Beginning on 03/09/26, RAs, CMAs and nurses had a demonstration done by the ED on the Resident Monitoring alert in the electronic health record (EHR) in guidance with the Alert Charting policy. This creates an alert for staff to increase monitoring and observations for the resident, for a limited period of time due to reasons such as a change in condition, admission, behaviors, return from hospital, and other incidents. If phone contact with staff was unsuccessful, staff education would be provided prior to beginning the next scheduled shift by the ED.

Beginning on 03/09/26, RAs were educated by the ED on Care Tracking Care Plan Interventions Charting in the EHR to ensure care tasks were performed per the resident's service plan. If phone contact with staff was unsuccessful, staff education would be provided prior to beginning the next scheduled shift by the ED.

Beginning on 03/09/26, RAs, CMAs and nurses were reeducated by the ED on walkie-talkies and the pagers sign in/sign out sheet. Walkie-talkies would be signed out by each RA, CMA or nurse at the start of each shift, and the charge nurse or charge CMA would ensure this was completed and documented daily. If phone contact with staff was unsuccessful regarding the education, staff education would be provided prior to beginning the next scheduled shift by the ED.

On 03/09/26, a contracted security company inspected the memory care's three exit doors for functionality of the panic bars. The contracted security company was unable to fix the non-functioning panic bar on the kitchenette exit door.

On 03/09/26, a motion sensor outdoor light was installed above all three outside doors of the memory care unit in the courtyard by ESD #83.

On 03/11/26, the ED and HSD were educated by RDO #94 and RDHS #93 that a minimum of four nursing staff (RA/CMA/nurses) would be maintained on the 10:00 P.M. to 6:00 A.M. shift facility wide, and staffing on each unit (memory care and assisted living) would be no less than two staff members on the night shift, starting immediately.

On 03/11/26, a contracted security company fixed the panic bar on the memory care kitchenette exit door.

On 03/16/26, the ED/designee began to audit the walkie-talkies and pager sign in/sign out sheet for compliance. The audit would be conducted three times a week for four weeks, then twice a week for four weeks then once a week for 4 weeks.

On 03/16/26, the ED/designee began to audit the door alarms on the memory care unit for function. The audit would be conducted three times a week for three weeks, then twice a week for three weeks then once a week for two weeks. Door alarm inspections would continue weekly.

On 03/17/26 at 6:00 P.M., the facility implemented one additional staff member on the memory care unit to conduct a door watch of all three memory care exit doors until the memory care pagers were confirmed working correctly. The additional staff member would be in effect until there was a confirmation of the door alerts signaling to the memory care pagers; however, there were secondary measures in effect such as a second audible alarm in place. For call-offs: the person in charge at the community would place calls to other staff members to pick up shifts. The second step would be calling the HSD and/or ED. If no one was available to cover the door watch, the following call tree will be put into place: 1. Opening shift for agency pick up. 2. HSD would cover the shift. 3. ED would cover the shift. The ED would ensure compliance.

On 03/17/26, the contracted pager company shipped a new paging transmitter to repair the signal for the pager system which was replaced and implemented on 03/19/26. The paging system was modified to be universal, for all pagers to include the assisted living and the memory care in the notifications.

On 03/20/26 at 6:15 A.M., the door watch additional staff member was removed when the facility confirmed all three security features for three all doors were working appropriately.

On 03/20/26, the ED/designee began auditing three times per day, on 03/20/26, 03/21/26 and 03/22/26, to confirm the notifications to the pagers from the paging system were working for the assisted living and the memory care unit. The audit would continue three times a week for three weeks, then twice a week for three weeks then once a week for two weeks.

Findings include:

Review of the medical record for Resident #65 revealed an admission date of 05/07/25 with diagnoses of dementia with hallucinations and delusions, psychotic affective disorder, diabetes, atrial fibrillation, and status post myocardial infarction. Resident #65 resided on the secured, memory care unit.

Review of the safety care plan dated 10/29/25 revealed Resident #65 required every two-hour safety checks and to monitor for signs of elopement.

Review of the Change in Condition evaluation dated 01/16/26 revealed Resident #65 was severely cognitively impaired and had a poor attention span. Resident #65 ambulated independently, wandered as a pattern and was goal oriented (going home, looking for someone, etc.) and/or had poor decision-making skills and/or not easily redirected.

Review of the undated Elopement Risk Evaluation revealed Resident #65 was at high risk for elopement.

Review of the observation progress note dated 03/08/26 timed 4:30 P.M. authored by the Health Services Director (HSD) revealed outside (on premise) on 03/08/26 at 9:30 A.M., Resident #65 was observed outside lying down on the grass in the memory care courtyard. Resident #65 was alert to person only. Two staff members assisted Resident #65 back into the building and helped the resident into the shower. Resident #65's blood sugar was 468 mg/dL and his temperature was 90.0 degrees F. The note indicated staff were unable to obtain any further vitals due to the resident shaking. Emergency Medical Services (EMS) was called and took the resident to the emergency department. POA, physician and ED notified.

Review of the Palcare report (the facility's pager system) revealed a door sensor at an unknown location was activated on 03/08/26 at 4:38 A.M.

Review of the National Weather Service Climatological Data for Akron Area on 03/08/26 revealed the minimum temperature was 43 degrees F.

Review of the March 2025 Medication Administration Record (MAR) revealed Resident #65's blood sugar check scheduled for 7:00 A.M. was not recorded until 11:58 A.M. At that time, Resident #65's blood sugar was 548 mg/dL.

Review of the emergency department physician progress note dated 03/08/26 timed 11:28 A.M. revealed Resident #65 with history of dementia, diabetes, hypertension, chronic kidney disease, atrial fibrillation presented to the emergency department after he was found alone, outside. He was unaccounted from around midnight until he came in around 11:00 A.M. EMS noted he was hyperglycemic as well as hypothermic. He did receive five units of insulin prior to arrival. He was unable to provide any history. Clinical impressions noted the resident with hypothermia (low temperature), tachycardia (high heart rate), elevated brain natriuretic peptide (BNP) level (a hormone produced by the heart to diagnose heart failure), altered mental status, elevated lactic acid level (inadequate oxygen delivery to tissue) and hyperglycemia (elevated blood sugar). Vital signs were consistent with hypothermia, and he was placed on the Bair hugger (forced air warming system). Examination and history were as noted above and was very limited as the patient was not answering questions and he was unaccounted for nearly 11 hours at nursing home. The note stated they would administer a small bolus of intravenous fluids. The physician did not believe the patient required an insulin drip for diabetic ketoacidosis (DKA). It stated the Resident #65 would be admitted to the intensive care unit (ICU).

Review of the After Visit Summary dated 03/09/26 revealed Resident #65 was admitted to the ICU for close monitoring and a Bair hugger. His temperature had remained in the normal range and did not require Bair hugger after initially getting into the emergency department. The principal problem/diagnosis was hypothermia due to exposure.

Review of the observation progress note dated 03/09/26 timed 6:37 P.M. revealed Resident #65 returned from the hospital at 6:20 P.M. via transport. Resident #65 was pleasant upon arrival and had no complaints of pain. Resident #65 had bilateral bruising to upper extremities and no other skin issues observed at that time.

Review of the Self-Reported Incident dated 03/08/26 revealed neglect/mistreatment abuse was alleged/suspected when Resident #65 had an unwitnessed fall outside the memory care side door. On 03/08/26 at 10:08 A.M., Resident #65 was observed on the ground outside of the memory care side door in a puddle, in the secured courtyard. Resident #65 was checked for injury and 911 was called and the resident was transported to the hospital for evaluation. The facility substantiated abuse, neglect or misappropriation verified by evidence.

Review of the nursing staff shift assignments for night shift from 03/07/26 into 03/08/26 revealed CMA #87 and RA #92 were the only nursing staff in the whole facility to care for 69 residents, 18 residents of which resided in the secured memory care unit. CMA #87 was scheduled to work on 03/07/26 from 6:00 P.M. to 6:00 A.M. on and RA #92 was scheduled to work on 03/07/26 from 10:00 P.M. to 6:00 A.M.

Review of the undated witness statement authored by the ED revealed on Sunday, 03/08/26 at 10:08 A.M. the HSD was notified by LPN #88 that Resident #65 was observed on the ground outside of the memory care side door in a puddle. The ED was then notified at 10:17 A.M. The resident was wearing jeans, two shirts and a baseball cap. His socks and shoes were off and next to him. The care staff got him inside and into his room to get him changed and cleaned up and 911 was called. The HSD arrived at the building, and Resident #65 was transported to the hospital for further evaluation. The statement stated upon investigation, RA #92 was assigned to the memory care and CMA #87 was assigned to the assisted living. Resident #65 had returned to the building around 2:30 A.M. [on 03/08/26]. RA #92's last check on Resident #65 was approximately 4:40 A.M. and the resident was assisted to the bathroom, then back to his recliner. It stated according to the call log, the memory care side door opened at 4:46 A.M.

Review of the elopement witness statement authored by RA #92 dated 03/08/26 revealed Resident #65 arrived back from the hospital anywhere from 1:00 A.M. to 1:30 A.M. [on 03/08/26] and EMS put him in his bed, to which the resident then tried to follow EMS out the door. To best of RA #92's knowledge, Resident #65 was wearing a brown USA hat, blue shirt and jeans/khaki pants. Resident #65 insisted on following RA #92 around, so he let him, and he let Resident #65 wait for him as he completed checks and changes on other residents. Resident #59 and Resident #66 then were around Resident #65. Resident #65 started yelling at Resident #66 to drop her gun and get on her knees claiming people were shooting at him and the building, anytime between 2:00 A.M. to 2:30 A.M. RA #92 finished up more checks and changes and then came out of Resident #69's room around 3:00 A.M. to see Resident #65 urinating on the floor. RA #92 then cleaned the floor and answered a bunch of pagers just as RA #92 had been doing all night. Around 4:00 A.M. to 4:30 A.M., RA #92 started another round of checks and changes. Around 4:40 A.M., RA #92 got to Resident #65. Resident #65 was wearing a pair of underwear and shirt, so RA #92 got him a brief and he sat back in his chair around 4:50 A.M. RA #92 answered some pagers going off up front [on the assisted living side of the facility]. As soon as RA #92 returned to the memory care unit around 5:00 A.M. to 5:15 A.M., RA #92 finished up the checks and changes, informed first shift everything that was or wasn't done and had let them (unnamed) know that Resident #65 had come back from the hospital. He took out the trash and left.

Review of the elopement witness statement authored by CMA #87 dated 03/08/26 revealed Resident #65 returned from the hospital between 1:00 A.M. and 2:00 A.M. [on 03/08/26]. The RA (unnamed) and CMA #87 made sure the resident was safely put in his bed. It stated we worked short staffed the night of 03/07/26 leading up to the morning in question. At 5:30 A.M., there was a fall and the RA (unnamed) and CMA #87 had to work together to help Resident #13.

Review of the elopement witness statement authored by RA #91 dated 03/08/26 revealed RA #91 was assisting another resident when her coworker (unnamed), also working in memory care first shift, alerted RA #91 that Resident #65 had been outside for an extended period of time. RA #91 noted she had no prior knowledge of the resident's whereabouts as third shift did not let her know whether the resident was still in the hospital (as he had a fall the day prior) or with a family member. RA #91 remained inside with the other residents after coworkers RA #86 and LPN #88 went outside to find Resident #65.

Review of the elopement witness statement authored by RA #86 dated 03/08/26 revealed RA #86 got to work at 8:00 A.M. and began the shift. RA #86's coworker, another RA (unnamed), arrived at 6:00 A.M. It stated last night [03/07/26] while RA #86 was working, Resident #65 was sent to the emergency department for a fall so when RA #86 arrived [in the morning of 03/08/26], RA #86 asked if he was still out to which RA #86 was told yes by the other RA as that was the impression she was under. At around 9:30 A.M., the nurse (unnamed) was doing a med pass and asked where Resident #65 was. RA #86 told the nurse he was still out and she said, no I have his paperwork. They began to look in every room then the nurse radioed RA #86 from outside asking RA #86 to come out. RA #86 walked outside and Resident #65 was shaking and they couldn't understand much of what he was saying. They got Resident #65 inside and slowly warmed him up after getting his wet clothes off. They got the mud off and put him in dry clothes and wrapped him in warm blankets while waiting for EMS.

Review of the undated elopement witness statement authored by LPN #88 revealed this nurse was passing medication on the assisted living side at the beginning of the shift. She arrived on the memory care unit at approximately 8:45 A.M. and began medication (med) pass in the memory care. Resident #65 was not observed in dining area. The nurse continued medication pass through consistent interruptions and began walking to Resident #65's room. The nurse noticed Resident #65 was not in bed, so the nurse checked the bathroom which the resident was not observed. The nurse radioed RA's (unnamed) to begin searching the unit for the resident. After searching all rooms and bathrooms on the unit, the nurse searched the perimeter outside and observed Resident #65 in face down on the ground, his hands were folded in front of him with his head resting on his hands. The nurse called Resident #65's name and the resident mumbled words unclear to the nurse. The nurse radioed for RAs to assist the resident in the building to his room. RAs (unnamed) and the nurse arrived in the resident's room, immediately removed his clothing and checked for any injuries. Resident #65's hands, feet and face were red and cold to the touch. A warm shower was given and warm clothes and a blanket were applied. 911 was activated by another nurse on shift [LPN #84]. Vital signs were attempted but could not retrieve except his blood sugar was 548 mg/dL. All other parties were notified of the incident by the HSD.

Review of the elopement witness statement authored by RA #85 dated 03/07/26 [incorrectly dated] revealed the memory care used the walkie and asked for help. RA #85 and RA #82 went back [to the memory care unit]. Unnamed staff were outside with Resident #65 on the ground in the mud, he was sitting up shaking with no socks and shoes on. They picked him up and got him into his bathroom where he became combative. He wouldn't let them take his clothes off, so they had to cut them off and get him showered. They got him out and the nurse (unnamed) called EMS. The HSD came in and took his blood sugar and gave insulin then EMS arrived.

Review of the elopement witness statement authored by RA #82 dated 03/08/26 revealed RA #82 was in the assisted living and was called back [to the memory care unit] to assist a resident that was observed in the courtyard at 10:11 A.M. RA #82 went outside and Resident #65 was on the ground and alert to self. They assisted the resident back inside to his room, arm in arm with two RAs and nurse. They got the resident into the shower to clean up, got him out, sat him down, got him dressed, and called the squad.

Review of the elopement witness statement authored by LPN #84 dated 03/08/26 revealed the nurse was called to assist in Resident #65's room. The nurse observed the resident sitting on his bed getting dressed by an aide (unnamed). Resident #65 was shivering and his vital signs and blood sugar were assessed at that time. LPN #84 called 911 and printed out the emergency department packet.

During an interview on 03/16/26 at 8:20 A.M. CMA #81 stated when she arrived to work on 03/09/26 at 6:00 A.M., Resident #65 was at the hospital. CMA #87 reported to CMA #81 that Resident #65 got out.

On 03/16/26 at 8:43 A.M. the area outside where Resident #65 was found was observed. It was an enclosed courtyard. RA #82 was present during the observation and said Resident #65 was found underneath a tree where the ground was muddy and wet. RA #82 stated on 03/08/26 and around 10:00 A.M. or 10:30 A.M., he was called via walkie talkie that the staff needed help in the memory care unit. RA #82 saw Resident #65 outside, standing, shivering and his clothes were muddy. The staff assisted the resident inside and had to cut his clothes off because the resident wouldn't allow the staff to remove his clothes. The staff gave Resident #65 a shower before the resident was sent to the hospital. RA #82 stated Resident #65 had a history of exiting seeking and would be looking for his wife or his truck and would open the doors to the outside enclosed courtyard.

During an observation on 03/16/26 at 8:50 A.M., CMA #81 opened the door twice in the memory care kitchenette to the outside enclosed courtyard however the pager CMA #81 was carrying did not alert that a door was opened.

During an observation on 03/16/26 at 9:10 A.M., Resident #65 was walking independently out of his room into the hallway.

During an interview on 03/16/26 at 9:45 A.M. with LPN #84 revealed LPN #84 worked the weekend of 03/08/26. When LPN #84 observed Resident #65 on 03/08/26, the resident had been showered because the resident was filled with mud from head-to-toe and was sitting on the bed shivering really bad and she stated he had hypothermia at that point.

During an interview on 03/16/26 at 10:32 A.M., RA #86 stated she worked the weekend of 03/07/26 on the memory care unit. On 03/07/26 around 6:00 P.M. or 7:00 P.M., Resident #65 was sent to the hospital for a fall. When she arrived at 8:00 A.M. on 03/08/26, she started working with RA #91 who had started working that day at 6:00 A.M. on the memory care unit and was the RA who got the shift report from the night shift staff. RA #91 told RA #86 that Resident #65 was still out at the hospital, so RA #86 hadn't been checking on Resident #65 all morning. Around 9:00 A.M. or 9:30 A.M., RA #86 was changing another resident when LPN #88 asked where Resident #65 was. RA #86 or RA #91 told LPN #88 that Resident #65 was still at the hospital to which LPN #88 stated Resident #65 was back from the hospital because LPN #88 had his hospital paperwork. The staff started searching all the resident's rooms and didn't find him. LPN #88 used the walkie talkie to say, come outside right now. Resident #65 was lying in a puddle, rolling and shaking, muddy and wet. Resident #65 was very disoriented and grunting stating, what are they doing to me. RA #86 stated she hadn't observed Resident #65 exit seeking but had heard that when he would go out of the facility, like to the hospital as he did that day, Resident #65 got confused.

During an interview on 03/16/26 at 10:45 A.M., RA #85 stated she worked last the weekend of 03/07/26. RA #85 was working with RA #82 in Resident #15's room (on the assisted living) when they received a call asking for an RA to go to the memory care unit, so both RA #85 and RA #82 went to the memory care unit. Outside by the 100-hall door, Resident #65 was sitting on the ground in a puddle, wet and muddy, shivering and not saying anything coherent. The staff assisted the resident off the ground, got him inside, showered, warmed up and sent him to the hospital. RA #85 stated Resident #65 had wandering behaviors.

During an observation on 03/16/26 at 11:05 A.M., Resident #65 walked from the memory care dining room into his room. Resident #65 had a basketball size bruise on his right forearm. Resident #65 did not have any recollection of being outside and falling in a puddle last week.

During an interview on 03/16/26 at 12:45 P.M., the ED stated LPN #88 called the HSD on 03/08/26 at 10:08 A.M. regarding Resident #65 being found outside and the pager report showed the 100-hall memory care door alarm activated on 03/08/26 at 4:46 A.M. The ED verified Resident #65 was not accounted for on 03/08/26 from approximately 4:46 A.M. to 10:08 A.M. The ED stated the staff did not get the notification of the 100-hall door alarm on the pagers that night and the door alarm screamer had been turned off.

During an interview on 03/16/26 at 2:10 P.M., RA #91 stated Resident #65 had a history of wandering around the memory care unit. RA #91 stated when she arrived on 03/08/26 at 6:00 A.M. for her shift, she didn't know and wasn't made aware that Resident #65 had gone out to the hospital on 03/07/26 and had returned the morning of 03/08/26. RA #91 stated at 6:20 A.M., she checked Resident #65's room and the resident wasn't there. RA #91 assumed Resident #65 was with a family member. RA #91 was the only RA on the memory care unit until RA #86 arrived at 8:00 A.M. Around 9:30 A.M., they realized Resident #65 was missing. RA #86 and LPN #88 went outside to help Resident #65 while RA #91 stayed inside with the other memory care residents.

During an interview on 03/16/26 at 2:40 P.M., the ED and HSD verified the memory care unit was left unsupervised on 03/08/26 when RA #92 had to leave the unit to assist CMA #87 when Resident #13 (who resided on the assisted living side of the facility) fell at approximately 5:30 A.M. or 5:45 A.M.

During an interview on 03/16/26 at 2:45 P.M., RA #92 stated Resident #65 had a history of wandering and exit seeking. On 03/07/26 at 10:00 P.M., RA #92 arrived for his first night shift and RA #92 and CMA #87 were the only staff in the entire facility. At approximately midnight, RA #92 did his first rounds on the memory care unit and answered pages from residents on the assisted living, so the memory care was left unsupervised for 30 minutes. At approximately 1:00 A.M., RA #92 reentered the memory care unit to finish the rest of his rounds. At approximately 1:00 A.M. or 1:30 A.M., Resident #65 arrived back from the hospital when RA #92 opened the door for EMS to enter the memory care unit. EMS put Resident #65 to bed, but Resident #65 tried to follow EMS out of the memory care unit. RA #92 got Resident #65 a snack and a drink because Resident #65 was attempting to eat invisible snacks out of his hands. At approximately 2:00 A.M. to 3:00 A.M., RA #92 did another round of checks and changes. Resident #65 had urinated on the floor in the hallway. At approximately 4:30 A.M., RA #92 began another round of checks and changes. At 4:45 A.M. or 4:50 A.M., RA #92 got to Resident #65. Resident #65 was sitting in his bedroom in a high-back chair, and he assisted him back to the chair. After RA #92 was finished with Resident #65, RA #92 received a lot of pages up front (in the assisted living) from Resident #8 and Resident #36 and he exited the memory care unit to assist those residents. CMA #87 had also needed assistance when Resident #13 (in the assisted living) fell and needed urine cleaned up. At approximately 5:20 A.M. or 5:30 A.M., RA #92 returned to the memory care unit to finish rounds and then RA #91 arrived. RA #92 told RA #91 that Resident #65 had returned to the facility from the hospital.

During an interview on 03/17/26 at 10:15 A.M. with LPN #88 stated she arrived to work on 03/08/26 a little after 6:00 A.M. and got report. LPN #88 then did the incident report for Resident #65's fall from 03/07/26. LPN #88 began medication pass on the assisted living side, had quite a few interruptions, and made it back to the memory care unit at approximately 8:30 A.M. or 8:45 A.M. The residents were still in the dining area and LPN #88 began passing medications. LPN #88 was about to give Resident #65 his medications but was interrupted again. After the interruption, LPN #88 went to Resident #65's room and he wasn't in his room. The RA (unnamed) at that time had told another RA (unnamed) that Resident #65 had gone with family. LPN #88 stated Resident #65 was back from the hospital. Resident #65 was then found lying outside the 100-hall memory care exit door, on his stomach with his head in folded hands. LPN #88 called an RA to assist and the HSD. The staff got his wet clothes off him and got him warm. LPN #88 tried to get vital signs, but he was shaking too badly. LPN #88 called for LPN #84. By this time, the HSD arrived and EMS was called. LPN #88 stated the RAs were supposed to do walking rounds so she assumed that all the residents were accounted for. LPN #88 revealed Resident #65 would get in moods every so often and would exit seek at times.

During an observation on 03/17/26 at 11:30 A.M. with the ED and ESD #83 revealed each of the three memory care exit doors to the enclosed courtyard had three security features to alert staff when a resident was attempting to exit the facility: a red alarm screamer attached to the top inside of the door that would alarm loudly locally and could be deactivated with a key; a magnet device attached to the door and door frame which would send a notification to the pagers and facility computers when the door was opened; and the panic bar on the door would alarm locally when the panic bar was pushed. The ED and ESD #83 tested the 100-hall memory care exit door to the patio (the door Resident #65 likely exited) by opening the door, however a page was not received on a memory care pager per the security feature. The ED stated it was found during the investigation that the night shift RA was not carrying a memory care pager to be alerted that a memory care door had been opened.

During an interview on 03/18/26 at 11:35 A.M., Resident #65's family member stated Resident #65 had a history of wandering and exit seeking. Resident #65's family member stated Resident #65 could have died when he was outside from approximately 5:00 A.M. to 9:30 A.M. or 10:00 A.M. Resident #65 was found lying outside in a puddle, barefoot. Resident #65's family member stated it was very disturbing and the family was worried about Resident #65 exiting the facility again.

Review of the facility's Resident Admission Agreement Exhibit 11 regarding Special Populations dated October 2022 revealed it was the purpose of the community to provide a quality living environment to residents who may require assistance with personal care, intermittent nursing, monitoring and supervision, but do not require 24-hour skilled nursing care. The community's ability to meet residents' needs shall be based upon a comprehensive pre-admission assessment of the resident's physical, health and social needs; preference and capacity for self-care. There were three shifts spanning 24 hours, caregivers and licensed nurses would be staffed 24 hours a day.

Review of the facility policy titled Wandering and Elopement Prevention Plan Program, revised on 07/12/22 revealed the purpose of the policy was to provide a system for identification of residents at risk for unsafe wandering and elopement, provide a program of supervision and interventions to minimize risk to resident elopements and elopement attempts, and provide team member education wandering and elopement management through in-services and elopement drills. Residents that had been identified as an elopement/wandering risk based on their elopement risk evaluation score would have an individualized serve plan/care plan that included interventions to minimize the potential for elopement. The individualized service plan/care plan would be created and shared with resident (if appropriate), residents responsible party and community team members. Designated memory care doors regarding courtyard doors: alarms were set to alarm staff when residents enter or exit into the courtyard and staff would be trained to check promptly respond to door alarms.

Review of the facility policy titled Resident Abuse and Neglect, revised on 03/10/23, revealed neglect was a pattern of conduct or inaction by a person or entity with a duty to care for or provide goods and services that maintain physical or mental health of a vulnerable adult, or that avoids or prevents physical or mental harm. It also included an act or omission that demonstrates a serious disregard of consequences to a degree that presented a clear and present danger to the vulnerable adult's health, welfare and safety.

This violation represents non-compliance investigated under Master Complaint Number OH00170063 and Complaint Number OH00169949.

Based on record review and interviews with staff the facility failed to ensure Resident #65 medication were properly reconciled with discharge orders to administer medications in accordance to prescriber instructions. This affected one resident (Resident #65) of three residents reviewed for medication administration. The census was 58.

Findings include:

Review of the closed medical record for Resident #65 revealed an admission date of 11/11/25 and a readmission date of 01/23/26. Diagnoses included dementia Alzheimer's type, insomnia and deborrheic keratosis. Resident #65 was cognitively impaired.

Review of the hospital discharge paperwork revealed Resident #65 was admitted to the hospital on 01/18/26 and discharged back to assisted living with hospice orders on 01/23/26. The discharge summary directed Resident #65 to stop taking Haloperidol lactate 2 mg and Seroquel 25 mg.

Review of the January 2026 Medication Administration Record (MAR) revealed Resident #65 had an order for Haloperidol (Haldol; an antipsychotic medication) 2.5 milligrams (mg) by mouth two times a day for agitation. It was administered on 01/24/26 in A.M., 01/24/26 in P.M. and 01/25/26 in P.M. It was held on 01/25/26 in A.M., held on 01/26/26 in P.M. due to lethargy and held on 01/27/26 in A.M. Resident #65 had an order for Quetiapine (Seroquel; an antipsychotic medication) 25 mg one time a day at bedtime. It was administered on 01/24/26, 01/25/26 and 01/26/26.

Review of the incident log from 08/15/25 to 02/10/25 revealed Resident #65 had a medication error on 01/28/26.

Review of the Medication Error incident report dated 01/28/26, timed at 7:42 P.M. and authored by Health Services Director (HSD) revealed Resident #65 was re-admitted to the facility on 01/23/26 in the evening. Resident #65 was admitted onto hospice care on 01/24/26. Orders were reviewed and new orders were obtained for hospice comfort medications. The hospital discharge orders from the discharge summary were not reconciled with previous orders. During the investigation of the incident it was discovered the facility could not locate the discharge paperwork from the hospital. The facility requested a copy at the time of investigation. The hospice nurse notified the Assistant HSD and ED on 01/26/26 that Resident #65 was more lethargic than usual. A medication review was initiated and orders to discontinue Seroquel and Haldol were given at that time. It was brought to their attention the medications were actually discontinued before Resident #65 returned to the facility. Facility notified the husband and the physician and Certified Nurse Practitioner. It was determined Seroquel 25 milligrams (mg) by mouth in evening was administered to Resident #65 on 01/24/26, 01/25/26 and 01/26/26. Haldol 5 mg by mouth twice a day was administered on 01/24/26 in the morning and evening and 01/25/26 in the evening and held other days with notification to physician due to observation of increased sedation. No adverse reactions were noted at the time and resident was at baseline during investigation. After the investigation of incident, it was discovered the discharge summary and orders from 01/23/26 were not located within Resident #65's chart or in the system. The facility thought it was a possibility hospice had accidentally taken the paperwork. CNP obtained orders from the hospital. Medication Tech (MT) #900 was scheduled on 01/23/26 from 06:00 A.M. to 06:00 P.M. LPN #215 was working 6:00 P.M. 10:00 P.M. MT #900 stated Resident returned around 8:00 P.M. LPN #215 denied doing order review or processing admission however acknowledged she was aware Resident #65 was scheduled to arrive around 6:00 P.M.

Interview on 02/11/26 at 2:31 P.M. with HSD revealed Resident #65's Haldol and Seroquel orders should have been discontinued upon readmission to the facility. The nurse (LPN #215) did not reconcile the medication list. LPN #215 told her she did not know where the discharge summary was. LPN #215 was supposed to notify the person on call (HSD) when there was a new admission or readmission and she did not do that. The next morning on 01/24/26 the nurse followed what was on the MAR. Hospice also came in that morning. Hospice did their reconciliation of what they had and added as needed comfort medications. Hospice brought it to HSD's attention on 01/27/26 of the medication errors. The physician was notified. The two medications were discontinued and staff were ordered to push fluids. Resident #65's husband was also notified.

Interview on 02/11/26 at 3:17 P.M. with HSD revealed Resident #65's January MAR showed she received medications verifying the Haldol and Seroquel dates and times they were given.

Review of the facility policy titled Medication Errors