The certified nursing assistant assigned to Resident #3 approached the nursing desk and reported the person was missing from their room. Licensed Practical Nurse #1 said the aide had heard the resident "arguing on the phone, was loud for a while, cursing, and then heard nothing and felt a draft."
When staff entered the room, they found the window wide open and the resident gone.
The facility initiated its elopement protocol and searched the grounds. During the search, they discovered a tree branch directly under the resident's window that "appeared split" and observed footsteps on the ground beneath the window.
The incident exposed fundamental failures in the facility's risk assessment process. Complete Care at Court House had conflicting information about whether Resident #3 posed an elopement risk, and staff never completed required safety evaluations.
Nursing Supervisor #1 had received information from a transferring facility about a previous incident involving Resident #3 that required security response. She completed an elopement section in her notes based on that conversation but stated "the Elopement Assessment was not completed because they were unsure if the resident had an actual elopement attempt or if it was a behavioral incident."
The facility's own records contradicted each other. An evaluation completed December 6 gave Resident #3 an "Elopement Risk Score of 99.0," indicating no risk was identified. But this conflicted with the nursing supervisor's concerns about the resident's history.
Licensed Practical Nurse #2 was supposed to complete an assessment on the same date, but inspectors found no evidence that any elopement assessment was actually finished.
During interviews five days after the escape, the Director of Nursing confirmed "the record contained conflicting information regarding Resident #3's elopement risk."
The facility's Medical Director explained the standard: when residents are admitted, staff should complete assessments including elopement risk evaluation. If someone is identified as an elopement risk, staff must "develop and implement appropriate interventions to prevent elopement."
None of this happened for Resident #3.
The facility's own policy, updated in September, requires staff to "utilize a systemic approach to monitoring and managing residents at risk for elopement." It mandates that "residents will be assessed for risk of elopement and unsafe wandering" and that care teams "evaluate the unique factors contributing to risk in order to develop a person-centered care plan."
The policy wasn't followed.
The resident who escaped through the second-floor window had a documented history that should have triggered safety measures. Information from the previous facility described an incident serious enough to require security intervention. Yet Complete Care staff spent weeks debating whether this constituted an elopement risk while taking no protective action.
The certified nursing assistant assigned to watch Resident #3 that night could not be reached for comment when inspectors tried to interview her.
The escape occurred despite multiple warning signs. The resident was agitated enough to engage in a loud, profanity-filled phone argument in the middle of the night. The aide heard the commotion, then noticed sudden silence and felt a draft - clear indicators something had gone wrong.
By the time staff discovered the open window, Resident #3 was already gone. The broken tree branch and footprints in the dirt told the story of someone who had climbed out a second-story window and dropped to the ground hard enough to snap wood.
Federal inspectors found the facility failed to ensure residents at elopement risk received adequate supervision. The violation affected few residents but created potential for actual harm - a classification that understates the danger of a nighttime escape through a second-floor window.
Complete Care's admission process broke down at the most basic level. Staff received clear information about a resident's behavioral history but couldn't decide whether it mattered for safety planning. While they debated, Resident #3 took matters into their own hands and climbed out a window into the December night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Court House, LLC from 2025-12-29 including all violations, facility responses, and corrective action plans.