Resident #2 required regular dialysis treatments but often refused them, according to MD G, who treated her at The Colonnades at Reflection Bay. The doctor said her cognitive decline meant "she did not always understand the importance of going to dialysis."
That created a dangerous situation when she went missing. MD G told inspectors that if Resident #2 eloped and missed dialysis, "there was a risk to develop uremia and cause confusion."
The facility's own records show she eloped at least twice in early June 2025. But when federal inspectors interviewed staff in October, nobody could provide consistent details about what actually occurred.
LVN FF said she wasn't working when Resident #2 eloped and "had only heard the staff looked for Resident #2 at she was not on the premises." The nurse said she knew someone brought the resident back inside "one time because she tried to go across the street."
A weekend supervisor gave a completely different account. That person told investigators the resident "asked another family member to take her across the street because she wanted to go get food." The family member took her to a restaurant, then she wanted to go to the other side of the parking lot. RN H went across the street and found the resident at the apartments.
The charge nurse provided yet another version. That nurse said the resident "refused medications an dialysis and was missing for approximately 20 minutes."
Three different stories. Three different staff members. Same incident.
The facility's internal investigation notes revealed the same confusion. Inspectors found "inconsistencies among staff on Resident #2's 06/21/2025 elopement" and noted there were "no staff or witness statements included in the meeting notes."
Even more concerning, the facility's own records suggested multiple elopement incidents that were never properly investigated. The inspection report noted "there was no investigation or information regarding a 06/05/2025 or 06/06/2025 elopement."
LVN FF described Resident #2 as "confused quite a bit and she tried to leave the facility a couple of times." The nurse said the only intervention she recalled was "to keep an eye on her."
That wasn't enough. By June 21, the facility had placed Resident #2 on one-to-one supervision around the clock. Monitoring sheets from June 28 through July 6 showed she remained on constant watch throughout each shift.
The facility scrambled to address the problems after the June incidents. Staff received elopement training on June 21 and again on June 27. An emergency quality assurance meeting was held July 1.
But the training materials revealed how unprepared staff had been. The June 21 in-service was completed "with no additional information included." The June 27 session at least reviewed the facility's elopement response policy.
That policy, dating to March 2012, required staff to complete a head-to-toe nursing assessment when an eloped resident returned. It also mandated notification of the physician and responsible party, plus documentation of the incident.
The policy warned that residents at risk for elopement "may be discharged" and required reporting to the Department of Aging and Disability.
By July 1, the facility updated all elopement risk assessments. The result was puzzling: "no residents were at risk for elopement." This assessment came just days after Resident #2 had been on constant supervision due to her elopement attempts.
LVN FF knew the basic protocol for missing residents: "search everywhere and if the resident cannot be found to notify the DON and have all staff start to look for the resident." But the facility's response to Resident #2's actual elopements fell far short of its own policies and staff knowledge.
Federal inspectors classified the violations as immediate jeopardy to resident health and safety. The noncompliance period lasted from June 5 through July 6, 2025.
The facility corrected the problems before the October inspection began. But the case highlighted fundamental breakdowns in both preventing elopements and investigating them when they occurred.
Resident #2's story illustrates the particular vulnerability of residents with cognitive decline who require life-sustaining treatments like dialysis. When such residents elope, the medical consequences can be severe, and the facility's ability to respond coherently becomes critical to their safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Colonnades At Reflection Bay from 2025-10-24 including all violations, facility responses, and corrective action plans.
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