The resident, identified in inspection records as Resident B, suffers from vascular dementia with behavioral issues and has been flagged as an elopement risk since at least March 2021. Care plans specifically noted the resident "may shake and push/fidget with doors in an attempt to leave the facility."
On July 22, residents were participating in a courtyard activity near the entrance door when Resident B walked around the secured area, went back inside, then somehow exited the building entirely. A certified nursing assistant on break spotted the resident near the driveway and parking lot.
"She asked the resident what they were doing and the resident said, I got out," according to the inspection report.
The Memory Care Coordinator told investigators she wasn't sure how the resident managed to leave the secured courtyard without being noticed. Security footage later revealed Resident B had been outside unsupervised for less than three minutes before the CNA brought her back inside.
But this wasn't the resident's first escape.
Facility records show Resident B had previously been "found wandering unsupervised outside of the secured courtyard fence" in another incident. The resident's care plans, dating back to 2021, specifically addressed "exit seeking behaviors" and recommended interventions including escorting the resident outside and using distractions.
The CNA who found the resident in the parking lot described the patient's escape patterns to investigators: "The resident did not have a lot of exit seeking behaviors but when she did, she is bad. The residents would go to every single door and try to open them."
Current assessments painted a picture of a vulnerable patient. The resident's August quarterly evaluation indicated severe cognitive impairment, though it noted "no current behaviors." Medical records listed anxiety, depression, vascular dementia with behaviors, and stage 3 chronic kidney disease among the resident's diagnoses.
Despite the facility's awareness of the resident's escape risk, supervision gaps allowed two separate incidents. The Memory Care Coordinator acknowledged the security concerns during her interview, saying she had reminded staff to ensure doors stayed closed tight and warned visitors and staff not to let anyone follow them off the unit.
The administrator reviewed security footage from the July incident, confirming the timeline: Resident B exited the building and was returned by the CNA less than three minutes later. But the brief window raised questions about what could have happened during those unsupervised moments near the parking lot and driveway.
Federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent incidents. Facilities must be particularly vigilant with cognitively impaired residents who demonstrate exit-seeking behaviors.
The inspection found Elwood Health and Living failed to provide proper supervision for the memory care resident, despite documented knowledge of the elopement risk and established care plans addressing the resident's door-testing behaviors.
Resident B continues to live in the memory care unit. The facility's security measures and supervision protocols remain under federal scrutiny following the citation for failing to prevent accidents and provide adequate oversight of vulnerable residents.
The parking lot where the resident was found sits directly adjacent to the facility's driveway, presenting potential risks for unsupervised patients who manage to breach the secured unit's containment measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elwood Health and Living from 2025-10-27 including all violations, facility responses, and corrective action plans.