She had already called the pharmacy twice about the losartan during her previous shift on Tuesday.
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The resident, identified in federal inspection records only as Resident #20, reported the fall on or around Friday, April 24, 2026.
The facility, located at 2971 Maple Avenue, had 49 residents at the time of the inspection.
She was severely cognitively impaired and could not speak for herself about her own care.
At Firesteel Healthcare Center, federal inspectors found that window was not being honored.
For 44 minutes on April 28, 2026, nobody at Bradley Health Care & Rehab knew where a dementia patient was.
The facility submitted its Quarter 4 Payroll Based Journal data to the Centers for Medicare and Medicaid Services on February 6, 2026, at 12:50 PM.
The violation was documented in a federal inspection report filed under a complaint investigation completed May 28, 2026.
Weeks later, the mat was not there.
Federal inspectors found the facility failed to follow a care plan for transfers for the resident, identified in inspection records as Resident 4.
The incident happened on May 18, 2026, at Momentous Health at Richfield, a 56-bed facility in northeastern Ohio.
The resident, identified in inspection records only as Resident B2, cannot perceive the need to toilet.