The resident left the facility at 6:21 PM, prompting administrators to initiate a "CODE WHITE" emergency response. Staff located the person six minutes later and transported them by ambulance to Self Regional Healthcare's emergency room for evaluation.
Federal inspectors arrived the same evening to investigate. The facility operates a wander guard system designed to sound alarms when residents at risk of wandering approach exit doors, but the system did not prevent this escape.
Nine residents currently wear wander guard devices at the facility. Maintenance logs show the electronic monitoring system underwent multiple inspections following the incident, with staff testing spare devices near exit doors on December 18, 22, 23, 24, 29, and 30.
The facility's administrator attempted to contact the escaped resident's responsible party but could not reach them or leave a voicemail because the phone system had not been set up.
An emergency quality assurance meeting convened December 15, attended by the medical director, administrators, nursing staff, and department supervisors. The medical director received notification of the incident on December 13 and again on December 18.
Inspectors observed the exit door system functioning on December 30, confirming alarms sounded loudly when wander guard devices came within proximity and doors remained locked.
The facility implemented new protocols requiring daily review of new admissions for elopement risk and weekly audits of wander guard observations. Two residents admitted between December 23 and 30 showed no exit-seeking behaviors, according to facility assessments.
Staff will receive additional training on determining causes when wander guard alarms sound.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Manor - Greenwood from 2025-12-30 including all violations, facility responses, and corrective action plans.