Abbotsford Health Care Center: Elopement Safety Failure - WI
The resident, identified in inspection records only as R1, had been admitted to the facility under guardianship. Her brain function scores placed her in the moderately impaired range. She wandered. She got confused about where she was, sometimes asking staff "where am I." Her own elopement evaluation, completed three weeks before the incident, noted a history of leaving or attempting to leave without informing staff.
None of that stopped what happened on July 22.
R1's guardian had called the facility that morning to say an eye appointment had been cancelled, the prescription needing verification first. The guardian wanted R1 kept at the facility. A licensed practical nurse, identified in the report as LPN C, went down to R1's room to relay that message. R1 was not there. LPN C searched. Another staff member mentioned they had seen R1 leave by transport. LPN C called the Director of Nursing.
R1 had arranged her own ride and left for an appointment her guardian had already cancelled, without signing out, without staff knowledge, without anyone stopping her.
When the state surveyor arrived on August 29, more than five weeks after the incident, she asked the Director of Nursing, identified as DON B, what documentation existed showing R1 had been signing out when she left the facility on prior occasions. DON B said she had none. Not for the day of the incident. Not for any day before it.
The surveyor then asked what interventions had been put in place after July 22 to keep R1 from leaving undetected again. DON B said R1's guardian had refused a wander guard. The facility had notified Adult Protective Services and added language to the care plan reflecting the guardian's wishes. DON B was not aware of any additional steps taken.
The facility's own elopement policy states that residents who exhibit wandering behavior or are at risk for elopement must receive adequate supervision to prevent accidents, with care delivered according to a person-centered plan addressing the specific factors that create that risk. R1's care plan, initiated in early July, had already identified that her guardian permitted her to leave the premises to smoke, since the facility is smoke-free, and that staff were to accompany her outside due to her altered mental status.
There is no indication in the inspection record that anyone was accompanying her.
Two certified nursing assistants, identified as CNA D and CNA E, told the surveyor on August 29 that they were aware the elopement had occurred. They said they had received no education about elopement procedures in the weeks since. A nurses meeting on August 14 had included some elopement training for licensed nurses, but DON B could provide no evidence that the broader staff, including the aides who work most closely with residents day to day, had received anything.
The surveyor asked DON B for the complete investigation file: resident interviews, staff interviews, documentation of the inquiry into how R1 left and what should change. DON B could not provide it. There was no evidence that resident or staff interviews had been conducted as part of any formal investigation.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. That designation reflects the regulatory finding. It does not reflect what could have happened to a moderately cognitively impaired woman, traveling alone to a medical appointment that had already been cancelled, in a transport van she arranged herself, while the staff responsible for her safety did not know she had left the building.
R1's guardian had previously given permission for her to go off premises to smoke. The care plan said staff were to be with her when she did, because of her altered mental status. Whether anyone had been following that instruction in the weeks before July 22, when she apparently left the facility on multiple occasions, is unknown. DON B had no records to show either way.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Abbotsford Health Care Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 27, 2026 · Our methodology
ABBOTSFORD HEALTH CARE CENTER in ABBOTSFORD, WI was cited for violations during a health inspection on August 29, 2025.
The resident, identified in inspection records only as R1, had been admitted to the facility under guardianship.
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.