The Laurels of Fulton: Resident Elopement Immediate Jeopardy - MI
That is how the facility learned Resident 101 was gone.
The resident, identified in inspection records only as R101, walked out of The Laurels of Fulton on the afternoon of Sunday, September 21, 2025, while staff were getting residents ready for dinner. She had recently returned from a psychiatric facility. She was supposed to be wearing an alarming device, a brand the inspection report does not name, that would have locked the front doors when she approached them. She was not wearing it. Nobody had noticed it was missing. Nobody had noticed she was gone.
When CNA G called in from outside, LPN D answered the phone. LPN D told inspectors she had no idea R101 had left the building. She went out to the parking lot with several other staff members and walked the resident back inside. R101 told them her mom had told her to go get some medicine.
CNA F, who had been working that afternoon, told inspectors in a telephone interview on October 8 that she had seen R101 at the nurses' station just minutes before CNA G's call came in. She did not know R101 had left. She did not know why R101 was not wearing the alarming device. She told inspectors the device, had it been on the resident, would have locked the front doors and stopped her from getting out.
LPN E, also working that Sunday, told inspectors she too had seen R101 chatting at the front desk. Then, a short while later, a CNA coming in for her shift called to say she had R101. LPN E went out to the parking lot to help escort the resident back in. After that, she assessed R101, put the alarming device on her, and entered her into the facility's elopement book.
The elopement book, it turned out, had not been updated. The Nursing Home Administrator had to be re-educated on the facility's own elopement policy. All staff had to be re-educated on both the elopement policy and the Missing Guest Procedure. The administrator was specifically retrained on what information needed to be gathered to ensure the policy was being followed across departments.
Federal inspectors classified what happened to R101 as Immediate Jeopardy, the most serious level of harm designation available under federal nursing home oversight, meaning the failure placed the resident in immediate risk of serious injury, serious harm, serious impairment, or death. The designation took effect September 21, the day R101 walked out. It was not lifted until September 22, after the facility completed a series of corrective actions.
Those actions included reassessing R101's elopement risk and putting new prevention measures in place, conducting a full resident count to confirm no one else had left the building, and evaluating every resident in the facility for elopement risk, including residents who had not previously been identified as at risk. The facility also reviewed and updated the elopement book, retrained all staff, and retrained the administrator.
Inspectors who arrived on October 8, 2025, for the complaint survey reviewed the facility's response and cited the violation as past noncompliance, meaning the deficient practice had been corrected before the onsite survey took place. The facility demonstrated monitoring of its corrective actions and was found to be in compliance as of September 22.
What the inspection record does not explain is how R101 came to be without her alarming device in the first place. She had recently returned from a psychiatric facility. The device was supposed to be on her. CNA F knew it should have been there. LPN E knew it should have been there. The front desk staff had seen her standing there, chatting, minutes before she walked out. Nobody checked.
The alarming device existed precisely for this situation. It would have triggered at the door. It would have locked the exit. R101 would not have made it outside. Instead, she walked down the road, far enough that a staff member driving in for her shift found her and called it in before anyone inside the building had started looking.
R101 told staff her mom had told her to go get some medicine. The inspection report does not describe her condition when she was found, does not say how far she had walked, does not say how long she had been outside. It was a Sunday afternoon in late September in mid-Michigan. The staff member who found her brought her back. That part went right.
The part that did not go right was everything before that. The device that was supposed to be on her was not on her. The staff who saw her at the nurses' station minutes before she left did not know she was a flight risk in that moment, or did not act on it. The elopement book was not current. The administrator needed to be retrained on a policy the facility already had.
The Laurels of Fulton is a long-term care facility in Perrinton, a small community in Gratiot County in central Michigan.
Federal nursing home inspection reports are public records. This article is based entirely on the CMS Form 2567 inspection report generated from the October 8, 2025 complaint survey at The Laurels of Fulton.
R101 was found down the road in a coworker's car, telling whoever would listen that her mom had sent her to get medicine. The front doors she had walked through were the same doors the alarming device was designed to lock. The device was somewhere in the building. She was not wearing it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Laurels of Fulton from 2025-10-08 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
The Laurels of Fulton in Perrinton, MI was cited for immediate jeopardy violations during a health inspection on October 8, 2025.
That is how the facility learned Resident 101 was gone.
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.