Resident #123 was last seen by staff at 5:30 PM on July 29, 2023, sitting in the television room. When a registered nurse went to check on the resident at 6:00 PM and found them missing from their room with an untouched dinner tray, the facility began searching. Police were called at 7:38 PM. The resident wasn't found until 9:40 PM when officers from an adjacent town located them at their last known address.
The incident triggered an immediate jeopardy citation from federal inspectors, who determined the facility had failed to adequately assess and protect a vulnerable resident. The violation ran from 5:30 PM when the resident was last seen until 9:40 PM when police returned them to the facility.
Hospital records from July 10, 2023, clearly documented that Resident #123 had a history of elopement and required staff supervision. The resident had severe cognitive impairment with a Brief Interview Mental Status score of 7 out of 15, indicating dementia. They could walk independently without assistive devices.
Despite these obvious risk factors, a licensed practical nurse completed an elopement risk assessment on July 14, 2023, that concluded the resident was not at risk for elopement. The nurse answered "Yes" to the resident being able to walk independently and having a history of elopement, but marked "No" for cognitive impairment or dementia diagnosis — despite the resident's admission record listing unspecified dementia.
An audit trail revealed the assessment was initially triggered as "at risk for elopement" at 11:52 PM on July 14. Six minutes later, at 11:58 PM, the same nurse edited the entry to reflect the resident was "not at risk for elopement at this time."
Because the resident wasn't classified as an elopement risk, no safety interventions were implemented. The resident's care plan included a focus area for cognitive loss due to dementia but no elopement prevention measures. No wanderguard alarm was placed on the resident. The third-floor unit where they lived had only a wanderguard system for the elevator — no electromagnetic locks on exit doors.
When questioned by inspectors, the nurse who completed the assessment said she couldn't recall details about completing or editing it. The Director of Nursing and Assistant Director of Nursing acknowledged the assessment inaccurately documented the resident's condition and that appropriate interventions should have been implemented for someone with dementia and elopement history.
The facility's investigation couldn't determine how the resident exited the building. Camera footage from the front lobby, back exit door, and first-floor stairway showed no sign of the resident during the timeframe. The facility had limited camera coverage at the time of the incident.
Staff interviewed the resident after their return. The resident told them they had walked out the front door and continued walking until they reached their apartment, planning to come back to the facility after their walk. A full body assessment found no visible injuries, though the resident complained of back pain and received medication.
The elopement exposed broader problems with the facility's medication management. During the inspection, surveyors found three residents who didn't receive prescribed medications for multiple days.
Resident #5 was supposed to receive Florastor, a probiotic medication, twice daily for gastrointestinal issues. During a medication observation on February 26, 2025, a licensed practical nurse told the surveyor there was no Florastor available in the medicine cart. The nurse said she would check a backup machine later but didn't notify the physician about the unavailable medication. Records showed the medication had been exhausted since January 22, 2025 — more than a month earlier.
Resident #32, who had Parkinson's disease and bipolar disorder, didn't receive Risperidone for five consecutive days in February 2025. The antipsychotic medication was prescribed for bipolar disorder, but medication administration records from February 18 through February 22 were left blank by nurses. The medication was available during this period but wasn't administered until February 23. No documentation explained the five-day gap.
Resident #352, who had Alzheimer's disease and glaucoma, missed Alphagan P eye drops for four days in July 2024. The medication prevents elevated eye pressure that can worsen glaucoma. A nursing note on July 7 indicated the physician was aware the medication was unavailable, but no physician notifications were documented for July 8, 9, or 10 when the medication continued to be withheld.
The facility's policy required nurses to check backup medication supplies, call the pharmacy for immediate delivery, notify supervisors and physicians, and document detailed medical record entries when medications weren't available. Staff interviews revealed these protocols weren't consistently followed.
When questioned about the missing medications, facility leadership acknowledged the problems. The Assistant Director of Nursing told inspectors they had provided education to staff about missing medications and notified physicians about the gaps.
The elopement incident prompted immediate changes. After the resident was returned, staff applied a wanderguard alarm and updated their care plan to include elopement risk with 30-minute monitoring intervals. The facility installed electromagnetic locks on the third-floor unit's double doors and provided staff education on elopement protocols.
The resident was admitted to the facility with multiple medical conditions including chronic pain related to tissue abnormalities and low back pain, in addition to dementia. Their cognitive impairment made them unable to understand safety risks or remember facility rules about staying in supervised areas.
Federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent residents from harm. Facilities must also ensure residents receive prescribed medications as ordered by physicians.
The facility submitted an acceptable removal plan on February 27, 2025, detailing corrective actions taken after the elopement. Inspectors determined the immediate jeopardy was past non-compliance, meaning the facility had corrected the specific problems but violations had occurred.
Resident #123 returned to the facility complaining of back pain after walking four miles to their former home. The incident lasted over four hours during which a vulnerable person with severe dementia wandered unsupervised through an urban area at night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careone At New Milford from 2025-03-06 including all violations, facility responses, and corrective action plans.