Lake Emory Post Acute Care: Dementia Patients Lost - SC
The incident at Lake Emory Post Acute Care on August 11 triggered immediate jeopardy violations after inspectors found the facility failed to supervise residents who were supposed to wear wander guards at all times.
Both residents had severe cognitive impairment. Resident 2 scored 6 out of 15 on a mental status exam and had been diagnosed with vascular dementia, Alzheimer's disease and chronic obstructive pulmonary disease. Resident 3 also scored 6 out of 15 and had vascular dementia. Their care plans specifically identified them as elopement risks requiring constant supervision.
The temperature reached 87 degrees that day.
Around 9 PM, the registered nurse on duty allowed the two women to go outside with other smokers but provided no escort or supervision, according to his written statement. He said the residents "verbalized attention to smoke and were last visualized at 2100." They were supposed to return in 15 minutes.
They didn't come back.
A certified nursing assistant assigned to both residents discovered they were missing when someone rang the doorbell around 9:30 PM. "I answered the doorbell, I thought it was my pizza," the aide told inspectors. "But it was two residents who were returning from outside and told me they saw two ladies outside."
The aide immediately checked their rooms. Empty.
She found the agency nurse and confronted him. "He said, I let two ladies out of this door a little while ago, that was about 8:30 PM - 8:45 PM," the aide recalled. "I figured I'd let them out to smoke and they'd be right back. He said they looked like they could be allowed outside, they looked competent."
The aide asked if he meant "one with a walker and one with sunglasses on." He confirmed it was them.
"I asked are they still out there. I walked outside and I didn't see them and started walking around the building," she said. She recruited help from other staff and searched the grounds.
Nothing.
When she returned to tell the nurse, he refused to call for help. "He said, I am not calling anybody until you check everybody in the facility," the aide told inspectors.
Only after they confirmed the residents were nowhere in the building did a nurse from another unit finally call the assistant director of nursing around 9:03 PM.
By then, the women had been missing for at least 20 minutes.
The assistant director of nursing got the call while three certified nursing assistants were already outside searching. "I heard the CNA say, Lets follow EMS as they passed the facility," she told inspectors. "They did and said they had found the two residents down [NAME] Road."
Emergency responders had spotted the women walking along the road after someone called 911. The EMS crew found them about 1.5 miles from the facility.
Resident 3 was in distress. She wore a long-sleeve shirt and pants with ballet-style slippers on the 87-degree evening. "She was very hot, sweating so bad. Her heart rate was 180, that is what EMS said," according to the nursing assistant who followed the ambulance.
Resident 2 had on a t-shirt and capri pants with tennis shoes.
The administrator arrived at the facility around 9:40 PM and drove to where the residents were found to measure the distance. "They were located about a mile down the road. I drove down to where they were located to be sure of the distance," he told inspectors.
EMS monitored both women's vital signs before bringing them back to the facility around 9:45 PM. They had been missing for approximately an hour.
The administrator confirmed there was no sidewalk where the women walked. "The sidewalk terminates so they either walked on grass or the road," the assistant director of nursing explained.
Another resident who had been shopping with family witnessed part of the incident. "We just got back from the store. We seen [R2 and R3] coming out the back door. They walked the property. They went toward the entrance and never came in," the resident told inspectors. "I went to the street, and I didn't see them."
That resident rang the doorbell to alert staff, which is how the nursing assistant discovered the women were missing.
Both escaped residents had physician orders requiring wander guards "at all times" with staff checking "function and placement every shift." Their elopement assessments noted they were disoriented, confused, and had histories of wandering.
Resident 2's assessment stated she was "not oriented to her surroundings" and "requires supervision, intervention, and wander guard." Resident 3's assessment noted she had "vascular dementia, not oriented to place or time, has a history of wandering."
Despite these documented risks, the agency nurse allowed them outside without any supervision or escort.
The facility immediately removed the agency nurse from duty and notified his agency that he could not return. Staff received emergency retraining on elopement policies and abuse prevention.
Inspectors found the facility's response inadequate given the severity of the incident. Federal investigators determined the lack of supervision constituted immediate jeopardy to resident health and safety.
The women could have been struck by vehicles, become dehydrated in the heat, or suffered falls while walking on grass and roadway without sidewalks. One already showed signs of heat stress with an elevated heart rate of 180 beats per minute.
Both residents returned to the facility that night without injuries, but the incident exposed systematic failures in protecting vulnerable residents with documented elopement risks.
The facility's own policy prohibited neglect, defined as "the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness."
Allowing two severely cognitively impaired residents to wander unsupervised for an hour on a hot evening fell squarely within that definition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Emory Post Acute Care from 2024-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
Lake Emory Post Acute Care in Inman, SC was cited for violations during a health inspection on August 14, 2024.
Both residents had severe cognitive impairment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Lake Emory Post Acute Care?
- Both residents had severe cognitive impairment.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Inman, SC, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Lake Emory Post Acute Care or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 425303.
- Has this facility had violations before?
- To check Lake Emory Post Acute Care's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.