LEHIGH ACRES, FL - Federal inspectors issued immediate jeopardy citations against Lehigh Acres Health and Rehabilitation Center after a resident with severe dementia and Alzheimer's disease walked out the facility's front door in August 2024, boarded a public bus, and was ultimately located approximately 16 miles away sitting outside a bar with no identification. The complaint investigation, completed August 24, 2024, revealed a chain of documentation and supervision failures that left a cognitively impaired resident completely unprotected.
A Resident Identified as High-Risk — But Never Protected
The resident, an elderly male, was admitted to the Lehigh Acres facility on August 7, 2024, from an acute care hospital. His diagnoses included dementia and Alzheimer's disease. From the very first day, clinical assessments painted a clear picture of a person who required close monitoring.
A licensed practical nurse scored the resident a 6 on the facility's elopement risk evaluation upon admission, categorizing him as not at risk for elopement. However, that same evaluation noted the resident was only oriented to person, experienced periodic confusion, and had a history of wandering. He was described as "discontent but agreeable to facility placement."
The very next day, a Speech Language Pathologist assessed the resident's cognition as severely impaired, scoring just 3 on the Brief Interview for Mental Status. The physical therapist documented the resident could walk 150 feet with minimal assistance and noted the resident's stated goal: "I want to go home." The therapist flagged that impaired cognition and safety awareness limited the potential for achieving rehabilitation goals.
The attending physician assessed the resident on four separate occasions between August 8 and August 16, documenting impaired cognition each time and ordering staff to monitor for worsening symptoms. A psychiatrist who evaluated the resident on August 15 documented that he was "very depressed, crying and confused," could not provide basic information about himself, and did not know where he was.
Despite this overwhelming clinical evidence, the facility's care plan contained no elopement-specific interventions. No wander alarm band was placed on the resident. No enhanced supervision protocol was initiated.
Warning Signs Documented but Not Acted On
The gap between documentation and action widened dangerously on August 16. At 3:50 a.m., a night-shift nurse documented that the resident was "alert with confusion," wandering the halls, and stating, "I am going down the street to my house."
This statement — a resident with severe dementia explicitly voicing intent to leave the facility — is one of the clearest elopement warning signs recognized in clinical practice. The facility's own elopement policy specifically identified "resident expressing he/she is looking to leave the facility" as a behavior requiring immediate re-evaluation of elopement risk.
Yet inspectors found no evidence that the night nurse communicated this critical change in behavior to the interdisciplinary team, re-evaluated the resident's elopement risk, or initiated any additional supervision measures. The resident continued through the day without enhanced monitoring.
Elopement risk evaluation in nursing homes involves a standardized scoring process. When a resident demonstrates exit-seeking language, confusion about their location, and physical ability to ambulate independently, clinical protocols call for immediate interventions including wander alarm placement, increased check-in frequency, updated care plans, and notification of the treatment team. None of these steps occurred.
The Evening of August 16: An Unimpeded Exit
The last documented staff interaction with the resident before his disappearance was at 5:22 p.m., when a certified nursing assistant recorded that he was eating. His scheduled 5:00 p.m. medications were administered.
According to the facility's own investigation, at approximately 7:10 p.m., the resident appeared in the front lobby fully dressed with a bag of clothes over his shoulder. The evening nurse observed him walking toward the lobby but was in the middle of receiving shift report from the outgoing nurse. She directed a CNA to ask the resident to return to his room, then continued receiving report.
The resident sat in the lobby for several minutes. The receptionist on duty noticed a neatly dressed man with a bag but did not recognize him as a resident. He was not wearing a wristband. When the receptionist made the customary announcement that visiting hours ended at 7:30 p.m., the resident stood up and walked toward the exit door.
As he approached the door, the receptionist asked if he was a resident or visitor. He stated he was a visitor and continued walking out the door. The receptionist did not call him back or verify his identity against any resident list. She locked the doors at 7:30 p.m. at the end of her shift without reporting the interaction.
It was not until approximately 8:45 p.m. — more than an hour and a half after the resident left — that a CNA informed the nurse that the resident was not in his room. Staff searched the facility and, unable to find him, notified the nurse manager. The elopement protocol was activated: 911 was called, the family was contacted, and local hospitals were alerted.
Found 16 Miles Away With No Identification
The resident's daughter later reported to inspectors that her father boarded a public bus and was dropped off in a downtown area approximately 16 miles from the facility, where he was found sitting outside a bar. He carried no identification and would not have been able to provide his own address.
The resident's implanted cardiac defibrillator activated during the incident, delivering an electric shock to restore his heart rhythm. He was subsequently hospitalized and, according to his daughter, was later placed at a different skilled nursing facility in a secured memory care unit — the type of unit the family had originally been told Lehigh Acres offered.
The resident's daughter told investigators that a case manager at the discharging hospital had indicated the facility had a memory care unit. Upon arrival, she discovered it did not. She voiced her concern to nursing staff, who told her they "monitor their residents all the time."
Clinical Staff Acknowledged the Danger
Interviews conducted during the investigation revealed that multiple clinicians recognized the resident posed a significant elopement risk — but none escalated their concerns effectively.
The Speech Language Pathologist told inspectors the resident was clearly cognitively impaired and "not safe to leave the facility unsupervised." He stated: "What made this resident's situation unsafe is the fact that he was very confused but very mobile."
The Physical Therapy Assistant described being "almost afraid to make the resident better physically due to his severe cognitive impairment," recognizing that improved mobility combined with impaired judgment created a dangerous combination. He noted the resident could walk approximately 300 feet independently and would not be able to make safe decisions such as avoiding traffic or identifying correct locations.
The attending physician stated that "anything bad could have happened" and that the resident "could have been seriously harmed." The psychiatrist confirmed the resident "could not be out on his own" and was not capable of making independent decisions.
The night nurse who documented the resident's exit-seeking behavior acknowledged to investigators that she should have placed a wander alarm band on the resident, stating that if she had done so, "the alarm would have gone off and [he] would not have left."
The facility administrator confirmed he was unaware of the therapists' concerns about the resident's elopement risk.
Corrective Actions and Additional Violations
Following the incident, the facility implemented several immediate changes. The front lobby door was locked permanently, requiring visitors to ring a doorbell for entry. A visitor badge and sign-in/sign-out system was established, with identity verification required for anyone attempting to leave without a badge. The Director of Nursing audited all 119 current residents for accurate elopement risk assessments, identifying one additional resident who required updated care planning.
Comprehensive elopement prevention training was initiated for all licensed nurses, CNAs, and therapists, with post-test evaluations required. Elopement drills were conducted, and the facility implemented a new protocol requiring identity verification before any person could exit.
The immediate jeopardy designation was removed on August 24, 2024, after surveyors verified implementation of the corrective actions.
Inspectors also cited the facility under F843 for failing to maintain a written transfer agreement with any Medicare- or Medicaid-certified hospital — a basic regulatory requirement designed to ensure residents can be transferred quickly when emergency medical care is needed. Both the Assistant Director of Nursing and the administrator confirmed the facility had no such agreement in place.
Understanding the Risks of Nursing Home Elopement
Elopement from nursing facilities is a recognized cause of serious injury and death among residents with cognitive impairment. Residents who leave facilities unsupervised face risks including exposure to extreme temperatures, traffic accidents, dehydration, falls, and the inability to obtain help due to confusion. In Florida, where summer temperatures routinely exceed 90 degrees, outdoor exposure poses particular danger.
The combination of severe cognitive impairment with preserved physical mobility represents one of the highest-risk profiles for elopement. Residents who can walk independently but cannot exercise judgment about safety require the most vigilant monitoring protocols, including wander alarm technology, locked or alarmed exit doors, and frequent visual checks.
The federal tag F689 addresses accident prevention, including elopement, and requires facilities to ensure the environment is as free from accident hazards as possible and that each resident receives adequate supervision to prevent accidents. An immediate jeopardy citation under this tag indicates that the deficiency caused, or was likely to cause, serious injury, harm, or death.
The full inspection report for Lehigh Acres Health and Rehabilitation Center is available through the Centers for Medicare & Medicaid Services and provides additional details about the facility's deficiencies and corrective action plans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lehigh Acres Health and Rehabilitation Center from 2024-08-24 including all violations, facility responses, and corrective action plans.
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