The first resident disappeared on November 2, 2025. The second walked away on January 20, 2026.
Both residents lived in the facility's north hall, which administrators said was the preferred placement for elopement risks when the memory care unit was full. The north hall had no outdoor access.
Federal inspectors who visited January 29 found the facility failed to adequately monitor residents at risk of wandering and didn't provide additional staff training after the first escape.
The Director of Nursing told inspectors she was "unsure when the last elopement drill had been completed." She also confirmed no additional education had been provided to staff members following the January 20 incident.
Staff were supposed to be notified of resident care needs through a quick reference guide called the Kardex and during shift change reports, including whether a resident had a roam alert device. When a resident went missing, staff would announce a "security alert" over the walkie system, stating the missing resident's room number.
The facility's policy, revised October 25, 2025, defined elopement as "any resident leaving the grounds of the facilities without knowledge of staff, or any patient/resident unable to be located on the grounds/facilities."
When a resident was discovered missing or a door alarm activated, the Director of Nursing or charge nurse was supposed to be immediately notified. At the care center, a beeper system connected to the call light system would activate, causing lights at the end of the affected hallway to flash red.
The Director of Nursing said she expected immediate notification when a resident eloped. For residents identified as elopement risks, the first consideration for placement was the memory care unit. If no beds were available there, the north hall was preferred because it lacked outdoor access.
Floor staff were allowed to initiate 15-minute visual checks for residents showing wandering or exit-seeking behaviors. The Director of Nursing said she expected staff to use PRN medication when available if residents showed signs of anxiety and pain.
An Improvement Advisor interviewed by inspectors confirmed that nurses had completed education and policy review following the November 2 elopement. However, the facility's elopement policy had been revised just three days before that incident occurred.
The inspection found the facility failed to ensure adequate supervision and monitoring of residents at risk of wandering. Federal regulations require nursing homes to provide care and services to maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Elopement incidents in nursing homes can result in serious injury or death, particularly for residents with dementia who may become disoriented and unable to find their way back to safety. The Centers for Medicare and Medicaid Services has identified wandering and elopement as significant safety concerns requiring systematic approaches to prevention and response.
The facility's policy stated it was the facility's responsibility to protect patients and residents from harm. Yet within three months, two residents managed to leave the grounds without staff knowledge, suggesting gaps in the implementation of safety protocols.
The timing of the policy revision, occurring just days before the first elopement, raises questions about whether staff had adequate time to understand and implement new procedures. The lack of additional training following the second incident suggests the facility may not have learned from the initial failure.
Both residents were placed in what administrators considered the safest location for elopement risks when the specialized memory care unit was unavailable. Despite these precautions and the facility's monitoring systems, both residents successfully left the premises undetected.
The inspection report documented actual harm to a few residents, indicating the elopements resulted in more than potential risk. The facility now faces federal oversight to ensure proper implementation of elopement prevention measures and staff training protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sanford Care Center Vermillion from 2026-01-29 including all violations, facility responses, and corrective action plans.
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