The resident, identified as Resident #90 in inspection documents, had been assessed as an elopement risk and was supposed to be protected by the facility's wandering prevention systems. Despite wearing a wander guard device designed to alert staff when residents approached exits, the person successfully left the building undetected.
Inspectors discovered the facility's own policies contributed to the security failure. The center's Wanderguards/Elopement Prevention Systems policy, dated February 2025, required wander guards for exit-seeking residents but failed to specify what staff should do when the alarms activated.
"Facility policies failed to define staff roles and required actions when a wander guard alarm activated, resulting in delayed response and resident elopement," inspectors wrote in their findings.
The policy stated it was "the policy of this facility that residents will be safe and secure in their environment" and that residents identified as exit-seeking "will have a wanderguard or similar device placed on their person, to assist in preventing them from wandering out of the facility and potentially being harmed."
But the document contained no instructions for staff response times, notification procedures, or specific actions to take when alarms sounded.
Resident #90's care plan before the incident included multiple interventions designed to prevent wandering. The plan called for staff to "check exit, stairwell and door alarms on a routine schedule for operability" and "check function of wander alarm per manufacturer recommendations." Staff were also instructed to "check placement of wander alarm every shift."
The care plan identified the resident's goal as reducing "episodes of exit-seeking behaviors" and ensuring the person "will not leave the facility without a responsible person."
Despite these documented precautions, the resident managed to leave the building.
Four days after the elopement, on December 28, Licensed Nurse #7 told inspectors the facility had modified the resident's care plan in response to the incident. The nurse said staff added a goal for the resident to "notify staff when he/she would like to go to the store."
Inspectors reviewed the revised care plan, dated November 20, and confirmed the addition of this single goal. However, they found no other new interventions designed to prevent future elopements.
The facility's Elopement/Wandering policy, updated in October 2025, required licensed nurses to complete specific actions after residents returned from unauthorized departures. The policy mandated nurses "review and update care plan and in room care plan/Kardex" and "update interventions."
But the minimal changes made to Resident #90's care plan suggested the facility failed to conduct the comprehensive review its own policies required.
The inspection revealed broader systemic problems with the facility's approach to resident security. While the center had established policies requiring wander guards for at-risk residents, the lack of clear alarm response protocols created gaps that allowed the elopement to occur.
Federal regulations require nursing homes to ensure residents receive care that prevents accidents and maintains their highest level of physical and mental well-being. Facilities must also provide adequate supervision to prevent residents from wandering into dangerous situations.
The inspection classified the violation as causing "minimal harm or potential for actual harm" to "few" residents. However, elopements can result in serious injuries or death when residents with cognitive impairments become lost or exposed to weather conditions.
Alaska's harsh winter climate makes unauthorized departures from care facilities particularly dangerous. Temperatures in Anchorage during December frequently drop below freezing, creating life-threatening conditions for elderly residents who may become disoriented outside.
The case highlights ongoing challenges nursing homes face in balancing resident safety with freedom of movement, particularly for people with dementia or other cognitive conditions that increase wandering risks.
Resident #90 remained at the facility following the incident, protected by the same flawed alarm system that had previously failed to prevent the elopement.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Centennial Post Acute from 2025-12-24 including all violations, facility responses, and corrective action plans.