Resident #2 left the facility grounds and walked to his previous residence, where his son found him. The patient had to ask his son to drive him back to the nursing home.
Nobody saw him leave.
Staff J, who was working that day, told investigators he was supposed to be supervising residents outside during the fireworks but acknowledged he wasn't watching when the resident disappeared. "Some residents with wander guards are 1:1 but supervision is expected at some level for all residents with a wander guard when outside," Staff J said.
The Director of Nursing was also working that morning shift when the elopement occurred. She admitted during her investigation that she couldn't determine any staff member was present outside supervising residents at the time.
"One of the pictures that Staff G took that day pictured her looking where Resident #2 should have been and did not realize that he was not," the DON explained to inspectors. She said Staff G and Staff B were outside, and Staff J was outside and first noticed the resident was missing.
But the DON couldn't identify who was actually watching the residents.
"The DON stated she could not determine that there was any staff present outside at the time of the incident supervising the residents," according to the inspection report. During her investigation, "nobody acknowledged they let Resident #2 outside."
Another resident provided the only clue about what happened. That resident told the DON "that Resident #2 had gone around the corner a while ago and he never came back."
Staff H was working the morning of July 3rd but wasn't outside during the incident. She told inspectors she had just arrived at the facility and was getting residents up when she learned about the missing patient.
"Staff H stated she was getting report from day shift CNA's and was told Resident #2 was heading away from the facility," the report states. She was then told to search for the resident and headed toward his previous residence.
The facility knew exactly where to look. Staff immediately suspected Resident #2 had walked to his former home, and that's where they found him with his son.
When staff located him, "Resident #2 requested for his son to take him back to the nursing home."
The DON acknowledged the supervision failure. "The DON acknowledged there was a lack of supervision during the fireworks activity for Resident #2 that led to his elopement."
She told inspectors that nursing staff should have remained outside with residents during the activity. "The DON stated it was nursing's responsibility for supervision outside. The DON stated one of the nursing department staff should have stayed outside with the residents."
Instead, staff were "coming, going and completing tasks inside at the time."
The resident wasn't injured during his walk to his former home. Staff completed an assessment when he returned, and his physician and family were notified of the incident.
Following the elopement, facility policy changed. The DON said Resident #2 is now assigned 1:1 supervision when outside.
She admitted the facility hadn't properly considered supervision levels for elopement-risk residents during group activities. "The DON stated at the time she did not know that there was a lot of thought that went into the level of supervision for any residents with a risk for elopement when outside for a group activity."
The facility's elopement policy, updated in October 2024, requires risk assessments upon admission and quarterly thereafter. Residents identified as moderate or high elopement risk should have alarm bracelets that "audibly alert the staff of attempts by the resident to exit the facility."
But the policy didn't prevent Resident #2 from walking away unnoticed during the July 4th celebration.
The case illustrates how quickly dementia patients can disappear when staff attention lapses, even during organized activities. Resident #2 managed to leave the facility grounds, walk to his former residence, and spend time with his son before anyone realized he was missing.
The DON's investigation revealed a fundamental breakdown in the supervision system designed to protect vulnerable residents from wandering off facility property.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Stanton from 2025-10-07 including all violations, facility responses, and corrective action plans.