They were.
A patient with dementia and a documented history of wandering had walked off the secured unit with a group of visitors on November 19. Staff discovered the escape only when police contacted them about finding the resident outside the facility.
RN #1 went with a police officer to bring the patient back. The nurse told inspectors the resident "walked up and down the halls" regularly and had a pattern of wandering throughout the secured memory care unit.
The escape happened during an unusually chaotic day. Between 7 AM and 3 PM, several groups of out-of-state visitors unfamiliar with the facility entered and exited the locked unit in groups of six to eight people at a time. A social worker was also visiting, and construction was occurring in the building.
"RN #1 further identified Resident #1 likely walked off the unit with exiting visitors," inspectors wrote.
The facility's own investigation confirmed this. The Director of Nursing told inspectors on December 18 that the resident was last seen seated in the lounge area right next to the locked exit door. Multiple unfamiliar visitors were on the secured unit that day, and the patient likely slipped out when one of the visitor groups left.
Nobody knows which staff member was supposed to be monitoring the door when it happened.
Nursing Assistant #2 worked the 7 AM to 3 PM shift that day and saw the resident walking in the hallway around 1 PM. The aide told inspectors the secured unit was "busier than usual" due to all the visitors entering and exiting, but said they didn't recall helping any visitors out of the unit.
The facility's own policies warned about exactly this scenario. The Elopement Prevention and Door Safety Policy identified that residents with dementia and wandering histories were at increased risk of escape. It specifically stated that "large groups of visitors presented a risk for unnoticed residents to exit the locked unit."
The policy required staff to "monitor exit doors more closely during peak visitor times and to ensure residents do not exit with visitors."
That didn't happen.
The Director of Nursing explained the security protocol to inspectors: staff should enter the door code to let visitors in and out, then stay at the door as people pass through. After visitors exit, staff must close the door and ensure it's secured, confirmed by a red light illuminating above the door.
Staff are never supposed to give the security code to visitors or residents.
But on November 19, the staff member who opened the door for visitors "must not have remained at the door to ensure no residents exited," the Director of Nursing told inspectors. After leaving the secured memory care unit, the resident walked through the facility's main entrance "unseen by the receptionist."
The facility couldn't identify which employee was responsible for the security breach.
Federal inspectors classified the violation as "immediate jeopardy" to resident health and safety, the most serious level of harm in nursing home regulations.
Civita Care implemented immediate corrections after the incident. All staff received retraining on the elopement prevention policy, including "rounding expectations, visual oversight of residents, alarm response and visitor monitoring."
The facility began daily audits for two weeks, then three times weekly for another two weeks, then weekly for a month. The audits checked that Wander Guard devices were working, door alarms were operational, care plans were accurate, and staff properly monitored visitors to ensure no residents left unsupervised.
The Administrator and Director of Nursing took responsibility for the corrections, with a compliance deadline of November 22.
When state inspectors returned on December 19, they found the facility had met all requirements for the corrective plan.
But for one November afternoon, a dementia patient with a known tendency to wander walked out of a locked memory care unit because staff failed to watch the door during the busiest visitor day anyone could remember.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Civita Care Center At Newington from 2025-12-19 including all violations, facility responses, and corrective action plans.