The resident at Optalis Health and Rehabilitation of Kingsford had been diagnosed with non-Alzheimer's dementia, anxiety disorder and depression. His cognitive assessment scored 7 out of 15 points on a standardized test, indicating severe impairment.
The June 30 incident began when Admissions Director C spotted the resident walking outside toward a local business while she was outside with another resident. She watched him enter the establishment and immediately radioed staff inside the facility to alert them.
"I was just outside of the facility with another resident. I saw R1 coming out of the facility door with visitors and announced on the two-way radio to alert the staff in the facility and kept watching him," Director C told inspectors during a September 16 interview.
Registered Nurse D, who was working in a different wing that day, heard the radio alert and walked to the business. She found the resident inside having a beer.
Social Worker B described the resident as someone who "prefers to be by himself and doesn't normally get dressed or up during the day." She said she heard the radio message about him being outside, left her office, and went to find him.
"His family came and drove him back to the facility as he was tired," Social Worker B told inspectors.
The resident was wearing a wander guard bracelet designed to prevent such incidents. But inspection records show the device failed to trigger an alarm when he exited through the facility's entrance door.
Staff noted during his return that "wander guard did not alarm at the entrance of the facility (where resident had exited)."
Despite the elopement - defined in facility policy as "a situation in which a resident leaves the facility without the facility's knowledge" - managers made no changes to the resident's care plan.
Nurse Manager E acknowledged to inspectors that "no new interventions were added to the care plan following the elopement." The Nursing Home Administrator and Director of Nursing made the same admission during their September 16 interviews.
This violated the facility's own written policy on elopement incidents. The policy, last revised in May 2024, specifically requires that "the care plan is updated" and "resident's care plan and interventions that address the resident's needs are reviewed and updated" when a missing resident has been located.
The resident had been admitted to the facility on July 24, 2024, just over 11 months before the elopement occurred. His Minimum Data Set assessment documented his multiple psychiatric and neurological conditions requiring specialized care and supervision.
Federal inspectors reviewed three residents for elopement-related issues but found deficiencies only in this case. They determined the facility "failed to provide adequate supervision" and created "potential for falls and injury" by allowing the resident to leave unattended.
The inspection was triggered by a complaint and resulted in a citation for failing to ensure the nursing home area remained "free from accident hazards" with "adequate supervision to prevent accidents." Inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
The case illustrates the challenges nursing homes face in balancing resident freedom with safety requirements, particularly for individuals with dementia who may not understand the risks of leaving supervised care. The resident's severe cognitive impairment would have made him unable to safely navigate traffic, weather conditions, or other hazards outside the facility.
His family's involvement in returning him to the facility suggests they understood his limitations and the importance of supervised care. But the failure of both the electronic monitoring system and staff oversight protocols left him vulnerable during the time he spent unsupervised in the community.
The facility's failure to update his care plan after the incident means similar episodes could occur again without additional preventive measures in place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Kingsford from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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