The resident had slipped out of Sunset Home's memory care unit early in the morning, triggering a Code Purple missing resident alert. Staff member CNA B eventually discovered the person lying on their side behind the Dollar General, with their right arm trapped underneath their body as they tried to hold themselves up.
"The resident said he/she had been out with the girls, hit his/her head on a rock and his/her arm hurt," CNA B told inspectors during a November 5 interview. The staff member covered the resident with a coat, then retrieved blankets from their car before calling the facility.
Where the resident's body touched the ground was wet. Ambulance staff recognized the left arm injury and avoided taking vital signs from that side during transport to the hospital.
The escape route appears to have been through the kitchen. Kitchen Aide A was taking a break outside the delivery entrance door around 6:30 AM when they spotted a figure walking past the propane tanks. The aide wasn't aware anyone was missing at the time.
"Looking back, he/she thought that it very well could have been Resident #1 but not really for sure," according to the inspection report.
The Dietary Manager had opened the door between the kitchen and memory care dining room between 6:00 and 6:30 AM that morning. The manager hung menus after talking with a staff member, then returned to the kitchen. Resident #1 was in the dining room during this time.
But the manager couldn't remember crucial details about the kitchen door.
"He/She thought the door to the kitchen was shut but does not remember and also did not remember if it was locked or not," inspectors documented. The manager didn't see the resident enter the kitchen, didn't observe them in the hallway, and didn't hear the back delivery door open.
The facility's security measures for memory care residents had gaps. Staff described the resident as "delusional and always thinks his/her sister, who has passed away is coming to pick him/her up." Despite this, the person was "easily redirected" according to staff accounts.
CNA A, who worked on both the North Hall and memory care unit, was off duty when the Code Purple alert went out. When they arrived at work, other staff told them which resident was missing. The CNA immediately started driving around the area searching.
"He/She parked in the parking lot of the Dollar General and did not see anyone," the report states. Only after parking and walking behind the building did the staff member locate the injured resident.
The dietary staff member who worked only four days a week said they had never seen any resident go through the kitchen during their shifts.
Following the incident, Sunset Home held emergency staff meetings that afternoon. The facility implemented several immediate changes: residents would receive 15-minute safety checks instead of the previous intervals, all residents would get visual safety checks every two hours, and management planned to change the doorknob on the memory care unit's kitchen door.
Additional alarms would be installed throughout the facility. The kitchen door would get a doorbell system as an extra security measure.
But for this resident, the security failures had already caused harm. The person was found lying on wet ground, injured and confused, after wandering alone for hours through an early morning that left them vulnerable to the elements and potential injury.
The ambulance crew's careful handling of the resident's injured left arm and the hospital admission suggest the fall behind the Dollar General caused significant physical trauma. The resident's statement about hitting their head on a rock indicates they may have suffered additional injuries beyond the obvious arm damage.
Federal inspectors classified this as an actual harm violation affecting few residents, documenting how the facility's inadequate security measures in the memory care unit directly led to a resident's injury and exposure to danger.
The case illustrates the particular vulnerabilities of memory care residents, whose cognitive conditions can drive them to seek family members who have died or attempt to leave facilities they don't recognize as home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunset Home from 2025-11-05 including all violations, facility responses, and corrective action plans.