Resident #18 lay curled on the ground with her knees to her chest, approximately 25 steps from the employee entrance near the Memory Care Unit courtyard gate at Altercare of Bucyrus Center. She had no walker or wheelchair with her.
The licensed practical nurse responsible for the Memory Care Unit and Hall 300 had left the building with a certified nursing assistant when the aide asked if she wanted to go outside to smoke. LPN #193 told inspectors that while outside, she asked CNA #146 to drive her to a local restaurant about six minutes away from the facility.
They got into the aide's car and drove toward the parking lot exit. By the time they reached the end of the lot, they decided they wouldn't have enough time and turned around.
That's when LPN #193 spotted the resident on the ground.
The nurse verified that when she left the building, only CNA #144 remained on the Memory Care Unit. No other staff were present to monitor Hall 300.
Resident #18 was repeatedly apologizing when they found her, saying she was on her way home. LPN #193 stated she didn't know how the resident could have made it outside without assistance.
The door alarm had been sounding for about five minutes before CNA #189 returned from her break and went to investigate. Looking outside, she found LPN #193 and CNA #146 helping Resident #18 back into the building.
CNA #189 retrieved a wheelchair. Once inside, staff seated the resident and cleaned her face while LPN #193 made multiple calls to the Director of Nursing, the resident's daughter, and emergency medical services for transport to the emergency room.
CNA #144, who remained on the Memory Care Unit during the incident, told inspectors the last time she saw Resident #18 was at 12:15 A.M. when she helped the resident to the bathroom. The aide said LPN #193 never told her she was going on a break and she was unaware the residents on Hall 300 had been left unattended.
Federal inspectors determined the incident violated multiple facility policies. The nursing home's elopement policy, last revised in May 2025, defines an elopement as when a resident leaves the facility unattended without staff knowledge.
The facility's work hours policy from May 2024 states that no employee is permitted to leave company property during breaks without special permission from their immediate supervisor. Staff may take two ten-minute breaks during an eight-hour shift.
Routine resident checks policy requires staff to monitor residents every two hours to ensure safety and well-being are maintained.
LPN #193 could not recall what time she left the facility during the October 22 incident. She confirmed she was the nurse assigned to both the Memory Care Unit and Hall 300 that evening.
The inspection found actual harm occurred to few residents. Federal regulators classified the violation as significant, indicating immediate correction was required.
The case emerged from two separate complaints filed against the facility. Master Complaint Number 2651195 and Complaint Number 2650725 both related to the same incident involving the resident found in the parking lot.
Resident #18 required emergency medical transport and hospitalization following her time on the ground outside the facility. The inspection report does not detail her injuries or current condition.
The violation represents a breakdown in basic safety protocols for vulnerable residents with dementia, who require constant supervision due to their cognitive impairments and tendency to wander. Memory care units typically maintain secured environments specifically to prevent such incidents.
Staff abandoning their posts to pursue personal activities while responsible for dementia patients creates immediate jeopardy situations. The five-minute door alarm suggests the resident may have been outside alone for an extended period before discovery.
CNA #144 remained unaware that residents under her indirect supervision had been left completely unattended while the licensed nurse pursued off-site activities during work hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altercare of Bucyrus Center Fo from 2025-10-28 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Altercare of Bucyrus Center Fo
- Browse all OH nursing home inspections