Incident investigation·February 12, 2026

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management. LPA met with facility facility nurse Carmen Bodnar, and explained the purpose of today's visit. The facility self reported an incident on 02/12/2026 documenting on 02/07/2026, Resident 1 received Ativan 0.5 mg tablets earlier than the physician’s prescribed administration times. During the 7:00 a.m. to 3:00 p.m. shift, Staff 1 assisted the resident with administration of Ativan 0.5 mg, which was given approximately 3.5 hours earlier than the physician’s order.During the 3:00 p.m. to 11:00 p.m. shift, Staff 2 assisted the resident 1 with administration of Ativan 0.5 mg, which was given approximately 4.5 hours earlier than the physician’s order.The physician’s order indicates Ativan 0.5 mg tablet, take one tablet by mouth three times daily.Staff 3 stated the computer has been updated to not allow the medication to be given earlier. Technical Violation was reviewed, and exit interview conducted with facility Facility Nurse Carmen Bodnar, , and a copy of this report provided.