The resident, known in the inspection report as Resident #3, had been admitted for short-term rehabilitation after fainting episodes caused by low blood pressure. Her admission assessment on the day she arrived noted she was "alert and oriented to person, place, and situation with no cognitive deficits" and posed no elopement risk because she "did not exhibit wandering or exit seeking behaviors."
That assessment was wrong.
Hospital records from before her nursing home admission showed she experienced hallucinations, had decreased safety awareness, and was impulsive. A state transfer form indicated she required a surrogate for decision making and was disoriented. Physical therapy evaluations noted her impaired safety awareness and fall risk due to her history of fainting and low blood pressure.
On October 29, 2024, at approximately 5:45 AM, Licensed Practical Nurse A was passing medications on the west wing when she noticed Resident #3 following her around and trying to enter other residents' rooms. The night supervisor redirected the woman to her room and asked her to wait for a nursing assistant to change her brief, then left her unattended while she went to find help.
Minutes later, a nurse from the east wing alerted the night supervisor that the exit door alarm had sounded. The supervisor couldn't hear the alarm from the west wing but immediately ordered a head count. Resident #3 was missing.
The night supervisor went outside and saw the woman walking down the road toward the gas station. She got her personal vehicle and drove to find her. "She described the resident was dressed in a pair of pants, short sleeve shirt, and gripper socks but was not wearing shoes," the inspection report states. Resident #3 was sitting on the ground near the door of the closed convenience store, combative and resistant to getting in the car.
Three police officers who were parked nearby helped get the woman into the supervisor's vehicle. They spoke with the facility administrator by phone to confirm she was a resident before assisting. The night supervisor returned her to the facility at approximately 7:00 AM.
The Director of Nursing instructed the night supervisor by phone to complete a head-to-toe assessment, place an electronic wander prevention bracelet on the woman, and assign her one-to-one supervision. But she was also told something else: don't document the incident in the resident's medical record or the facility's internal incident reporting system.
"She said it was her regular practice to document any changes or incidents in the resident's record but was told not to do so by the administration of the facility," the inspection report states.
When administrators arrived that morning, they watched security camera footage showing Resident #3 exiting through the east wing door, walking across the parking lot through low tree branches, and disappearing from view as she left the property. They could also see an east wing nurse close the door the woman had left through without going outside to look for residents.
The cover-up began immediately.
The Director of Nursing entered a sanitized note the next day claiming the resident "ambulated over to the door pressed on the egress bar and sounded the alarm. Staff responded to the resident and redirected back to her room." The note said the woman was "alert and oriented to person, place, and time" and just wanted to go for a walk, possibly because she had a urinary tract infection.
A urine test came back negative. The woman received no treatment for infection.
When federal inspectors arrived in January 2025 and asked about elopements, the Director of Nursing and Nursing Home Administrator said they weren't aware of any incidents. Only after being confronted with staff statements did the Director of Nursing return and acknowledge what she called a "near miss" — claiming the resident had only stepped into the parking lot under supervision.
"She explained the ADON received a call from the Night Supervisor during the morning hours of [DATE] to report resident #3 had opened the east wing front door and the alarm had gone off. She stated the Night Supervisor told the ADON she was right behind the resident when it happened, and she walked outside with her," the report states.
That wasn't true.
Multiple staff members confirmed the woman had made it to the gas station. An anonymous Licensed Practical Nurse told inspectors she saw Resident #3 with the night supervisor and police at the gas station at approximately 6:30 AM on her way to work. She said she found it odd that administrators assigned the woman a one-to-one sitter but claimed she had never left the parking lot.
"She found it odd for the DON and NHA to say resident #3 did not elope because, they don't put someone on one-to-one just for pushing the bar on the door like the DON documented on her note," the inspection report states.
The anonymous nurse said the Regional President of Clinical Services attended the morning staff meeting after the incident and read witness statements to department heads — something she had never done before. The statements implied the resident never left the facility's parking lot and made no mention of the gas station discovery.
A Certified Nursing Assistant who also requested anonymity said she witnessed the night supervisor at the gas station with Resident #3 and police that morning. She said staff were told this wasn't an elopement because the resident only made it to the parking lot, and that other incidents had been "swept under the rug by the administration."
The resident's daughter told inspectors she never received a call about the incident on October 29. She said she called the Director of Nursing and left messages but couldn't reach her. During a visit to the facility, she found a staff member sitting with her mother but got no information about what happened. She noticed her mother's clothes were still wet and muddy when she did laundry that day.
"She said her mother later expressed that she left the facility and went up the street. She said she was upset when she found out this happened to her mother," the inspection report states.
The facility's own elopement policy defined an elopement as occurring when a resident who was not alert and oriented was found outside the property line without staff knowledge, or when a resident was identified as missing. Resident #3 met both criteria.
A behavioral health physician who evaluated her after the incident found she had moderate cognitive impairment and administered a mental status exam showing a score of 16 out of 30. The physician noted that staff reported the resident "wandered and was actively exit-seeking." A score of 0 to 20 on the assessment indicated dementia.
The night supervisor provided cell phone records showing she made multiple calls to administrators between 6:20 AM and 7:10 AM on October 29 — four calls totaling 15 minutes with the Assistant Director of Nursing and three calls totaling six minutes with the Nursing Home Administrator.
She told inspectors that after speaking with surveyors by phone, the administrator told other staff not to speak to her and she feared for her job.
The facility's Medical Director said he was not aware Resident #3 had left the facility and walked to the gas station. When informed of the incident, he said it was concerning and that he had participated in quality assurance meetings about the elopement but couldn't recall details.
Regional executives ultimately suspended the Nursing Home Administrator and Director of Nursing pending investigation after learning the truth from staff interviews. A Regional President told inspectors the difference between what facility administration had told them and what they learned from staff was "egregious."
"Regional [NAME] President #1 stated they now knew the facility had internal issues which needed to be addressed. He said, 'You can't blame us because we only know what we are told,'" the inspection report states.
The Director of Corporate Compliance told inspectors it was "unethical, and an omission of truth to tell employees not to document an incident, to ask them to change their statements, or to falsify documentation."
The Medical Director, when finally informed of the full scope of what happened, told inspectors: "Every incident needs to be documented, and reported. Even if they get only part ways out, it needs to be looked into, even if they didn't get out the door." He added: "I'm so disgusted."
Federal inspectors found the facility had no elopement prevention plans or interventions for Resident #3 until the day after she walked to the gas station. She was discharged shortly after the incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Conway Lakes Health & Rehabilitation Center from 2025-02-01 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Conway Lakes Health & Rehabilitation Center
- Browse all FL nursing home inspections