The first elopement occurred July 26 when a resident left the facility around 7:30 p.m. Camera footage showed the resident, who used a wheelchair independently, exiting through the locked front door. A certified nursing assistant's badge had disabled the alarm sensor, allowing the door to unlock and the resident to leave undetected.
Six weeks later on September 12, another wheelchair-bound resident escaped using the same method. At 6:31 p.m., the resident left through the front door after CNAs used their badges to bypass the security system. The badge access released the lock, allowing both staff and the resident to exit together.
Both residents were classified as elopement risks. The facility maintained elopement binders at nurses' stations and the front desk containing photos and information about residents prone to wandering. Despite these precautions, the security system failures went unnoticed until after the residents had already left.
The nursing home's elopement policy, last revised May 14, required staff to evaluate every resident's escape risk upon admission and quarterly thereafter. The policy mandated that personnel immediately report any resident attempting to leave or suspected of going missing to the charge nurse.
Monthly elopement drills were supposed to be conducted, according to facility procedures. The policy also required that residents wanting to leave temporarily must have physician orders and sign out before departure.
When residents returned from unauthorized departures, the director of nursing was supposed to examine them for injuries, contact their physician and family representative, complete incident reports, update medical records and care plans, and conduct new elopement risk evaluations.
Following the July incident, the facility began implementing corrective measures on July 31. These included following quality assurance processes, educating all staff about resident elopements, and ensuring staff presence at the front entrance when residents were nearby.
The nursing home initiated elopement drills starting July 31 and continued them through November 27. Staff received in-service training September 16-17 covering the facility's elopement policy, the identification binders, and which residents posed elopement risks.
Federal inspectors reviewed camera footage of both incidents during their December 30 investigation. The footage confirmed that in each case, staff badge access had disabled the front door's security sensor, creating the opportunity for residents to leave undetected.
Interviews with staff revealed they understood the elopement education they had received. Inspectors observed that personnel were positioned at the front entrance when residents were present in the area, a practice implemented after the July escape.
The facility's weekly and monthly elopement drills showed ongoing efforts to prevent future incidents. Follow-up elopement risk assessments were completed as required by policy.
By the time of the December inspection, federal regulators determined the nursing home had achieved substantial compliance with elopement prevention requirements. The corrective actions implemented after both July and September incidents were confirmed as effective.
The inspection classified the violations as causing minimal harm with few residents affected. Both elopement incidents were considered past noncompliance, meaning the facility had corrected the deficient practices by the time of the federal review.
Neither resident suffered documented injuries during their unauthorized departures. The inspection report did not specify how long each resident remained outside the facility before being located and returned.
The badge-bypassed door sensors represented a critical failure in the facility's security system designed to protect vulnerable residents. Despite having policies, procedures, and identification materials in place, the technological safeguards proved ineffective when staff credentials could override them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Norton from 2025-12-30 including all violations, facility responses, and corrective action plans.