MURRAY, KY - A resident at Spring Creek Post-Acute Rehabilitation Center accessed an unsecured loading dock through a broken door lock and was discovered standing on a hydraulic lift elevated over 10 feet above ground, according to a federal inspection that found immediate jeopardy violations in April 2025.
High-Risk Resident Found on Elevated Loading Dock
On April 18, 2025, at approximately 2:58 PM, a resident identified as R529 traveled 71 yards from her room through multiple sets of doors, passed through a staff break room, and exited the building through a storage room door with a malfunctioning lock. The resident was discovered on the facility's loading dock, standing on a hydraulic lift raised 81 inches from the pavement below.
According to witness statements, Housekeeper 4 opened the door to the loading dock while looking for the Maintenance Director and immediately saw R529 on the elevated platform. "She started taking a couple of steps backwards," the housekeeper reported, prompting him to avoid startling her while he ran to get assistance. The Maintenance Director stated he "grabbed hold of the sweat shirt she had on and held her until staff came out to the dock" to prevent her from falling.
The incident represented a critical breakdown in the facility's supervision systems for a resident who had been assessed as high-risk for elopement just two days earlier.
Escalating Risk Assessments Without Enhanced Interventions
R529's elopement risk scores increased dramatically during her brief stay at the facility, yet protective measures failed to keep pace with her deteriorating condition. Admitted on April 3, 2025, with diagnoses including mild cognitive impairment and alcohol abuse, the resident initially scored 14 out of 15 on cognitive testing, indicating intact mental function.
Her first elopement risk assessment on April 9 yielded a score of 3, classified as low risk on the facility's scale of 0-5. However, by April 16—just one week later—R529's score had jumped to 13, well above the threshold of 12 that indicated high elopement risk. The facility responded by implementing a care plan that included monitoring her wander guard device every shift and instructing staff to report if they could not locate her.
Despite this intervention, R529's risk continued escalating. An assessment dated April 17 showed her score had increased to 14, yet inspectors found no evidence that additional safety measures were added to her care plan in response to this worsening trajectory. The comprehensive care plan documented that R529 exhibited behavioral problems including "walking around not clothed, picking at wounds, and taking dressings off her wounds," all indicators of confusion and impaired judgment.
Critical Door Security Failure
The resident's path to the loading dock exposed multiple security vulnerabilities. Video footage reviewed by inspectors showed R529 walking through two sets of double doors into the staff break room at 2:58 PM. A housekeeper was sitting at a table in the room with her head down looking at her phone. The housekeeper, identified as HK5, later told investigators she "never looked up from her phone" and did not see the resident enter the room or proceed through the storage door to the outside.
The storage room door that provided R529's exit route had a broken lock—a fact unknown to facility leadership and maintenance staff until after the incident. The Maintenance Director stated he had received no work orders about the malfunctioning door lock through the facility's TELS building management system. Critically, this exit door also lacked an alarm sensor for the wander guard system, meaning R529's ankle bracelet—which was functioning properly—could not alert staff when she passed through this particular doorway.
Elopement prevention in long-term care facilities relies on layered security systems. Wander guard technology uses radio frequency or infrared sensors at exit points to trigger alarms when residents wearing monitoring devices approach or cross thresholds. However, these electronic systems represent only one component of effective supervision. Physical barriers, visual monitoring, and environmental design must work together to protect cognitively impaired residents who may not recognize danger.
The broken lock on an unsecured door essentially created an invisible gap in the facility's protective perimeter. For a resident assessed as high-risk for elopement, this represented a serious hazard, particularly given that the door led to an industrial loading area with elevated platforms and mechanical equipment.
Confusion Over Incident Classification
Following the incident, facility leadership initially failed to classify R529's exit as an elopement, contributing to delayed reporting. The Administrator stated she "had been told R529 had not gotten out of the facility, and after discussion with the Director of Nursing it was decided it had not been an elopement." However, the Administrator acknowledged she "had not been aware the resident got out of the door and onto the dock."
This confusion over basic facts prevented appropriate incident response. The facility's own policy defined elopement as occurring "when a resident left the premises or a safe area without authorization and/or any necessary supervision to do so." By any reasonable interpretation, a cognitively impaired resident accessing an industrial loading dock through an unsecured door met this definition.
The Director of Nursing later acknowledged that "with the resident being found out on the loading dock, she would consider that an elopement" and stated "in hindsight yes, the incident should have been reported." The Station 2 Unit Coordinator confirmed that R529 "had tried to exit seek before," indicating a pattern of behavior that warranted heightened vigilance.
Cognitive Decline and Exit-Seeking Behavior
R529's clinical presentation suggested progressive cognitive impairment that significantly elevated her vulnerability. The MDS Nurse who conducted assessment interviews reported that "when she interviewed R529 for her MDS Assessment the resident had been confused at times." The Station 2 Unit Coordinator observed that "R529's cognition had changed drastically and she had gotten more and more confused," explaining why the facility conducted multiple risk assessments over a short period.
When cognitive impairment progresses, residents often lose awareness of environmental hazards and their own physical limitations. Exit-seeking behavior in dementia patients frequently stems from disorientation, attempts to return to former homes, or responses to internal stimuli that caregivers cannot observe. A resident who previously scored well on cognitive testing but shows rapid decline requires particularly careful monitoring, as their physical capabilities may exceed their judgment and safety awareness.
The facility's care plan included appropriate interventions such as "anticipating the resident's needs based on wandering triggers and patterns" and "diverting the resident's attention." Staff were instructed to "observe for exit seeking behaviors and patterns" and "redirect the resident from doors and exits as indicated." However, documentation and staff awareness did not translate into effective real-time supervision on the day of the incident.
Communication and Monitoring Gaps
The incident revealed weaknesses in how staff communicated and responded to safety concerns. When the Maintenance Director discovered R529 on the loading dock, he used the WhatsApp messaging application to alert other staff. The MDS Nurse reported seeing "a strange message on the WhatsApp that said, 'General Store. Resident needs help,'" which she did not immediately understand.
The use of informal messaging platforms for emergency communications can create confusion and delays. The facility's emergency preparedness documentation referenced a "Code Brown" protocol for resident elopement, designed to allow "the facility to quickly find any missing resident." However, the actual response relied on coincidental discovery rather than systematic search procedures. If the housekeeper had not needed to find the Maintenance Director at that particular moment, R529 could have remained on the elevated loading dock for an unknown period.
Following the incident, the facility implemented enhanced monitoring for R529, including 15-minute safety checks and relocation to "a room in a higher traffic area with a pathway by the nurse's station, dining, and therapy." These measures represented appropriate responses to demonstrated elopement risk but came only after the resident had already been exposed to serious danger.
Industry Standards and Regulatory Requirements
Federal regulations require nursing facilities to ensure each resident receives adequate supervision and assistance to prevent accidents. Facilities must identify environmental hazards, evaluate risks, implement protective interventions, monitor effectiveness, and modify approaches when necessary. For residents with cognitive impairment and wandering behavior, supervision requirements intensify proportionally to demonstrated risk.
The inspection findings resulted in citations for immediate jeopardy—the most serious category of deficiency, indicating a situation where facility practices have caused or are likely to cause serious injury, harm, impairment, or death. The immediate jeopardy determination reflected the life-threatening nature of R529's position on the elevated loading dock and the facility's failure to maintain basic environmental safety.
Inspectors validated that the facility removed the immediate jeopardy on May 10, 2025, after implementing corrective measures. The Maintenance Director installed a keypad lock on the storage room door immediately after the incident, eliminating unauthorized access to the loading dock area. The facility also enhanced monitoring protocols and relocated R529 to an area with increased staff supervision.
Additional Issues Identified
Beyond the elopement incident, inspectors documented that 16 residents were assessed as being at risk for elopement, indicating this represented a facility-wide management challenge rather than an isolated case. The facility maintained an "Elopement Binder" with information about at-risk residents and had policies addressing wandering behavior, yet implementation gaps allowed a high-risk resident to access a dangerous area unsupervised.
The internal investigation conducted by the facility initially concluded "there had been no failure with facility policies and processes," according to documentation reviewed by inspectors. This conclusion was unsigned and contradicted by the evidence, suggesting inadequate incident analysis procedures. The Administrator held an ad hoc phone meeting with the Maintenance Director and Director of Nursing but did not consult with the Medical Director about the incident, potentially limiting clinical input on appropriate interventions.
Staff training and awareness also appeared inconsistent. The housekeeper in the break room remained focused on her phone while a high-risk resident walked past her and exited through an unsecured door. Environmental rounds and safety checks apparently failed to identify the broken lock before it created a hazardous situation.
The inspection occurred following a complaint and involved both standard survey procedures and extended review to validate removal of immediate jeopardy conditions. The facility's census and staffing levels were not detailed in the report, though the presence of multiple residents requiring elopement precautions suggests significant care needs among the population served.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Creek Health Care from 2025-05-10 including all violations, facility responses, and corrective action plans.
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