The resident, identified in inspection records as having dementia and a cognitive test score of 4 out of 15, was discovered outside the facility on October 13 by an activities coordinator who redirected them back inside. The facility's own assessment classified the resident as high risk for wandering, with a score of 14 on their Wandering Risk Scale.
Despite having written policies requiring investigations of elopements, administrators decided the incident didn't qualify. The Assistant Administrator told inspectors on October 20 that no investigation occurred because "they did not think it was an elopement and there was no assessment completed on the resident because there was no visible injury."
The Administrator later acknowledged to inspectors that "the elopement was not investigated and it should have been."
Legacy Square's own policy defines elopement as any resident who leaves campus without informing staff or is found off campus in an unplanned location. The facility's algorithm for handling elopements requires completing an incident report and detailed medical record notation after a resident is found.
The resident had been equipped with a WanderGuard alarm system since April 2024, designed to monitor exit doors and prevent high-risk residents from leaving without assistance. But the Plant Operations Director confirmed to inspectors that if the WanderGuard malfunctions, "there is no way to keep the resident safe from elopement, and if a resident got outside unattended the doors would lock and they could not get back in."
Nobody could tell inspectors how long the resident had been outside alone.
The Director of Nursing admitted being "unaware of how long the resident was outside unattended" and confirmed "the resident should not be outside unattended." The Activities Coordinator who found the resident walking down the sidewalk also confirmed the resident "should not be outside unattended."
Records show the resident was originally admitted to Legacy Square with a diagnosis of dementia and a history of wandering. Their July 2025 assessment revealed they remained ambulatory and had "verbalized wanting to go home or to leave the facility." The facility's comprehensive care plan, last revised in December 2021, identified the resident as having "impaired cognitive function related to a diagnosis of dementia."
The inspection found that Legacy Square's reportable investigations for the past 12 months contained no records of any elopements, despite this October incident meeting their own policy definition.
Federal inspectors determined the facility failed to thoroughly investigate the elopement incident, creating potential harm for six residents identified as at risk for wandering. The facility housed 37 residents at the time of the October 23 inspection.
The violation represents a breakdown in the facility's safety protocols for vulnerable residents. While the resident was found and returned safely, the lack of investigation left unanswered questions about how the security system failed and whether other at-risk residents could similarly leave undetected.
Legacy Square's failure to follow their own elopement procedures meant administrators never determined what went wrong with the WanderGuard system, how long the resident was outside, or whether policy changes were needed to prevent future incidents. The resident with severe cognitive impairment had been walking alone on a public sidewalk with no staff supervision, despite being classified as high risk for wandering and requiring constant monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy Square from 2025-10-23 including all violations, facility responses, and corrective action plans.