Since 2018, at least 98 seniors with cognitive issues died after walking away from an assisted-living facility or being left outside unattended, an investigation by The Washington Post has found. Here is a list of those deaths, organized by state, along with the names of the facilities where they occurred.
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Facilities where seniors died after walking away or being left unattended
While The Post went to great lengths to compile a complete listing — reporters scoured state inspection reports, police records, lawsuits, obituaries and local media reports across the nation — this is certainly an undercount. Ten states did not provide any records and do not make inspection or incident reports available online. In some of those states, The Post found media reports of deaths and was able to verify them.
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Patients with memory problems walk away from assisted-living facilities just about every day in America; many die. The Post examines a pattern of neglect in America’s booming assisted-living industry.
See how your state regulates these facilities and read the full investigation.
Most facilities either did not respond or declined to comment; for those that did respond, their comments are included below. Some of the facilities have been sold, changed names or closed since the deaths occurred.
State inspection reports do not name residents involved in such incidents and The Post was unable to confirm the identity of the dead in every case.
Alabama
Elmcroft of Halcyon (Montgomery)
June 2019
Doris Mitchell, 82, died after being left alone in a hot van for five hours.
Alaska
Alaska does not make reports available online and did not respond to The Post’s request for information. The Post did not find media reports of deaths there.
Arizona
Silver Creek Inn (Mesa)
August 2022
Ina Jenkins, 88, wandered away and was found dead in an irrigation ditch.
Canyon Winds Retirement Community (Mesa)
July 2021
Lawrence Bearse, 90, was left alone in a van for 20 hours.
Scottsdale Memory Care (Scottsdale)
September 2020
Robert Cristall, 83, was left unattended on the facility patio.
Copper Village Assisted Living (Mesa)
June 2018
Mary O’Sullivan-Schultz, 70, was missing for more than a week before being found dead on a nearby property.
Brookdale Arrowhead Ranch (Glendale)
July 2020
Name withheld. The resident was left unattended on a hot patio.
Jackie Dickson, a spokeswoman for Brookdale, declined to comment on specific incidents but said the well-being of residents “always has been our top priority.”
Inspira Arrowhead (Glendale)
July 2023
Name withheld. The resident was found dead on a walking trail.
Casa Theresita II (Tucson)
2022 (Month undisclosed)
Name withheld. The resident was found on the facility grounds and could not be revived.
Arkansas
Brookfield Assisted Living (Bella Vista)
August 2021
Barbara Doyle, 74, wandered away and was found dead in a wooded area.
California
Cadence at Poway Gardens — The Palms (Poway)
September 2020
Gene Wilson, 84, got out of a secure area and fell 15 feet onto concrete.
The Terraces Compass Rose (Chico)
April 2018
Earl Simson, 99, was left unattended in direct sun on a patio for three hours.
Meadow Oaks of Roseville (Roseville)
June 2018
Claude Rogers, 83, was left unattended on facility patio for two hours.
Greenhaven Estates (Sacramento)
February 2019
Mildred Hernandez, 100, wandered outside at night and got locked out.
California Green Tree Villa (Los Angeles)
September 2019
Andrew Davis, 71, wandered outside and sustained a traumatic brain injury.
CalOaks Senior Living (Riverside)
July 2020
Brenda Ferguson, 55, was left unattended on a facility patio and was found with dehydration and burns.
Gardens of Riverside (Riverside)
September 2020
Anne Gacambi Methu, 70, was found on a facility patio with wire wrapped around her legs.
Courte at Citrus Heights (Citrus Heights)
June 2020
Name withheld. The resident was left unattended in a hot courtyard for nearly two hours.
Vaca Valley Living (Vacaville)
May 2021
Name withheld. The resident died of injuries sustained outside behind the facility.
Colorado
Applewood Our House (Lakewood)
January 2021
Lavina Bonacci, 88, was found in courtyard around 9 a.m. after going outside during the night.
Facility administrator Sherrie Bonham said: “We deeply feel and acknowledge the tragic circumstances we all experienced and express our most sincere empathy to everyone who this touched. Our dedication to making meaningful improvements is unwavering.”
Balfour at Lavender Farms (Louisville)
February 2022
Mary Jo Staub, 97, got locked out of the facility overnight in approximately 19-degree temperatures.
Cappella of Grand Junction (Grand Junction)
June 2021
Hazel Place, 86, was left unattended on a hot patio for six hours.
Pam Sullivan, a spokeswoman for the nonprofit chain that operates Cappella, said, “We continue to hold Ms. Place’s family in our thoughts and prayers and sincerely regret this unfortunate incident,” and that they have “added additional safety measures to ensure the well-being and safety of the older adults we have the privilege to serve.”
Mary Sandoe House (Boulder)
October 2020
Name withheld. The resident was found outside at 7 a.m. after going missing the previous night.
Carillon at Belleview Station (Denver)
October 2022
Name withheld. The resident left the facility and fell at a nearby restaurant.
Connecticut
The Post did not find any deaths in Connecticut’s publicly available records.
Delaware
Brookdale Hockessin (Hockessin)
October 2020
Name withheld. After a prior elopement, a resident went outside and jumped from a second-story balcony, resulting in fatal injuries.
Jackie Dickson, a spokeswoman for Brookdale, declined to comment on specific incidents but said the well-being of residents “always has been our top priority.”
District of Columbia
D.C. no longer makes records publicly available online. The Post reviewed available records.
The Marigold at 11th Street
March 2018
Eugene Hughes, 80, wandered out a kitchen door and fell from a loading dock.
Florida
Woodmont Senior Living (Tallahassee)
December 2020
Annie Lois Hanna, 100, was found with a walker outside on a cold morning.
Victoria’s Retirement Home (Lauderhill)
September 2021
Yvanne Moise, 69, was found in a car parked in the facility lot four days after wandering away.
Violet Gardens (Port St. Lucie)
June 2019
Jane Railey, 85, wandered outside overnight and drowned in the facility’s swimming pool.
Certus Premier Memory Care Living (Orange City)
May 2021
Armando Brazzoni, 89, wandered outside onto busy roadway and was struck by a vehicle.
Dayspring Senior Living (Hilliard)
December 2021
Felix Charles, 69, was found in a wooded area two days after wandering away.
Douglas Adkins, the facility’s administrator, said the incident occurred “due to the complexity of his situation and despite our best efforts.”
Promise Pointe at Tampa Oaks (Temple Terrace)
June 2022
David Taylor, 91, wandered outside and into a roadway, where he was struck by a vehicle.
Inspired Living Assisted Living (Delray Beach)
May 2023
Brian Yoder, 66, was found in a canal several hours after wandering away.
Brookdale Destin (Destin)
December 2020
Name withheld. The resident was locked outside overnight in freezing weather for about 16 hours.
Jackie Dickson, a spokeswoman for Brookdale, declined to comment on specific incidents, but said the well-being of residents “always has been our top priority.”
Georgia
Happy’s Manner (Lithonia)
August 2019
Henry Thompson, 86, was found dead under a deck six miles from the facility.
Sunshine Care (Lincolnton)
July 2020
Joseph Talbert, 66, wandered away and was never found.
Hapeville Manor Assisted Living (Hapeville)
November 2019
Ozzie Murphy, 60, was found unresponsive at a church with hypothermia.
Vine Senior Care (Flowery Branch)
August 2020
Name withheld. The resident got out of the facility and died by suicide in the woods.
Willow Creek Centerville (Centerville)
January 2021
Name withheld. The resident was found in a ditch a quarter of a mile from the facility.
Hawaii
The Post did not find any deaths reported in Hawaii’s publicly available records.
Idaho
Palouse Hills Assisted Living and Memory Care (Moscow)
January 2021
Jerry Kendall, 77, wandered outside and was found dead in a residential backyard.
Royal Plaza of Olympus Living (Lewiston)
June 2023
Debra Barnes, 66, was struck by a vehicle late at night after leaving the facility.
Illinois
Aspen Creek of Troy (Troy)
January 2023
Kathleen “Kitty” Kinkel, 77, wandered out of the facility on a cold night and was found in a field.
The Auberge at Orchard Park (Morton Grove)
January 2021
Bertrand Nedoss, 87, was found on the ramp of a neighboring parking garage.
Cordia Senior Living (Westmont)
February 2021
Regina Adamik, 96, was left overnight in a van in cold temperatures.
Gurnee Place Memory Care (Gurnee)
July 2021
James Hedrich, 82, was found in a pond three days after disappearing.
Indiana
Bethesda Gardens (Terre Haute)
January 2019
Veronica Laswell Hofmann, 75, was found outside the facility before dawn in freezing weather.
Iowa
Courtyard Estates at Hawthorne Crossing (Bondurant)
January 2022
Lynne Stewart, 77, was found outside a facility door after spending the night in subzero temperatures.
Justin Wray, chief operating officer of the facility’s owner, Jaybird, said the company takes elopements “very seriously.” He added: “The challenge is that you have people taking care of people and at times individuals didn’t follow the policies or the procedures set forth.”
Keelson Harbour (Spirit Lake)
December 2021
Elaine Creasey, 95, was found outside the facility after spending the night in freezing weather.
Justin Wray, chief operating officer of the facility’s owner, Jaybird, said the company takes elopements “very seriously.” He added: “The challenge is that you have people taking care of people and at times individuals didn’t follow the policies or the procedures set forth.”
Kansas
The Post did not find any reported deaths in Kansas’s publicly available records.
Kentucky
Kentucky does not make reports available online and denied The Post’s requests for records. The Post learned of deaths from media reports and independently confirmed them.
Fern Terrace of Owensboro (Owensboro)
June 2019
Joe Welsh, 70, was found dead by a river three days after going missing.
Countryside Meadows (La Grange)
July 2019
Raymond Hinkle, 65, was found dead in the lake of a nearby park.
Facility director Shawn Zamir said in a brief phone interview that his facility is not required to be a locked unit, nor was there a requirement for residents’ rooms to be alarmed.
Louisiana
Louisiana does not make reports available online and denied The Post’s requests for records. The Post found no deaths in media reports.
Maine
Maine does not make reports available online and asked for more than $800 to provide records. The Post learned of a death from media reports and independently confirmed it.
Woodlands Memory Care of Rockland (Rockland)
December 2021
Name withheld. The resident was discovered in the snow in a facility courtyard.
Maryland
Chestnut Grove Assisted Living (Dayton)
August 2022
Michael Hickey, 84, was found in a neighboring residential driveway with a head injury.
Massachusetts
Communities at Golden Pond (Hopkinton)
September 2023
An 84-year-old resident spent two nights outside in a brushy area near the facility.
Michigan
Vista Springs Timber Ridge Village (East Lansing)
December 2022
Lois Kathryn Cary, 82, wandered outside in a blizzard and was discovered by a snowplow driver.
Franklin Terrace (Southfield)
September 2019
Robert James Brunsden Sr., 88, was found in a river by a search dog a month after disappearing.
Green Acres (Fenton)
November 2021
Althea Green, 79, wandered onto a rural property, where she was found dead.
American House Senior Living Jenison Cherrywood (Jenison)
October 2023
Calvin Powers, 83, was found lying face down in the rain after 2 a.m.
American House Senior Living Kentwood Cobblestone (Kentwood)
June 2022
Name withheld. The resident drowned in a pond behind the facility.
Mallard Cove Assisted Living (Petoskey)
February 2023
Name withheld. The resident was found a quarter of a mile from the facility without winter clothing.
Minnesota
Golden Nest Assisted Living (Minneapolis)
March 2018
Kum Sun Melcher, 76, was discovered by her family lying in a snowbank.
Shorewood Commons (Rochester)
October 2020
Marian Keefe, 84, was found half a mile away after leaving in the early morning.
Heathers Manor (Crystal)
March 2022
Name withheld. The resident was locked out of the facility and tried to get back inside for more than two hours. The resident was found dead seven hours later.
New Journey Residence (Eveleth)
November 2018
Name withheld. The resident was found on exterior stairs with a severe head injury and frostbite.
Mississippi
Mississippi does not make reports available online. The state said in response to a request that there were no records of walkaway deaths.
Missouri
The Post did not find any reported deaths in Missouri’s publicly available records.
Montana
Montana does not make reports available online and said the information The Post requested was not readily available. The Post did not find any deaths in media reports.
Nebraska
Nebraska has stopped publishing reports online in recent years.
The Villa at Crown Pointe (Omaha)
February 2020
Robert Freymuller, 80, was found after falling outside the facility in subzero temperatures.
Nevada
Pacifica Senior Living Green Valley (Henderson)
August 2021
Andrew Louie, 56, was found by police outside the facility in high heat conditions.
New Hampshire
New Hampshire does not make reports available online and will not release complaint investigations in response to records requests. The Post learned of one death from media reports and independently confirmed it.
Tamworth Community Living (West Ossipee)
September 2018
Dwain “Dewey” Poulin, 82, was found in a mountainous area near the facility two years after he went missing.
New Jersey
The Post did not find any reported deaths in New Jersey’s publicly available records.
New Mexico
The Post did not find any reported deaths in New Mexico’s publicly available records.
New York
New York does not make reports available online and did not provide records in response to The Post’s request. The Post learned of one death from media reports and independently confirmed it.
Adirondack Manor Willow Park (Utica)
December 2021
Terry Rolfe, 67, was struck by a car on Christmas Day.
North Carolina
Arc of Dunn (Dunn)
August 2021
Joseph H. Matthews, 77, wandered away and was found the next day on nearby property covered with fire ants and bee stings.
North Pointe (Randleman)
January 2022
Thelma Lorraine Armstrong Wray, 89, was discovered lying outside in the snow next to her walker.
Tranquility Care (Winston-Salem)
May 2022
Vielace Rudolph Tippett, 77, wandered into a road and was fatally struck by a tractor-trailer.
Hermitage Retirement Center (Rockingham)
April 2023
Laddie Joel McKenzie, 70, fell from a 16-foot-high porch and was discovered dead nine hours later.
North Dakota
Maple View Memory Care (Fargo)
October 2020
Robert McKinnon, 80, was found in an unoccupied commercial building 12 days after disappearing.
Ohio
Otterbein-Cridersville SeniorLife Community (Cridersville)
July 2019
Orval “Bud” Hengstler, 89, drowned in a pond on the facility’s property.
Renaissance of Richfield/Bath (Richfield)
January 2022
Peggy Jirousek, 75, walked outside in the night and died in the snow.
The Merriman (Akron)
November 2022
Joan L. Meredith, 82, walked outside alone and was found dead two days later in the cold.
Forest Hills Place (Cleveland Heights)
December 2022
Francis Washington, 72, was found dead in single-digit temperatures outside the building.
Woodside Senior Living (Bedford)
January 2023
Annie Lee Luckett, 92, was found dead outside. She walked out in the early morning and slipped on ice.
Oklahoma
The Post did not find any reported deaths in Oklahoma’s publicly available records.
Oregon
Hawthorne House (Forest Grove)
April 2021
Toufik Tanous, 79, was found dead in a creek about a mile from the facility.
Rock of Ages Mennonite Home (McMinnville)
April 2020
Name withheld. The resident left the facility in a wheelchair and fell after going down a hill.
Pennsylvania
Wesley Enhanced Living at Stapeley (Philadelphia)
July 2018
Barbara Jones-Davis, 78, wandered out and fell onto a sidewalk below the property.
New Life Personal Care (McKeesport)
September 2019
Sam Davis, 75, was found dead at the bottom of a stairwell.
Richard Catalano, an attorney for the facility, said Davis was known to regularly leave the building and return. “You are not allowed to restrict the mobility of the residents. They are free to come and go as they so choose.”
Hillside Manor Personal Care Home (Uniontown)
March 2020
Amy Morris, 65, was locked out of the facility and hit by a car a half-block away.
Brandywine Living Senior Suites (East Norriton)
February 2022
Vera May Gower, 96, was found dead after being unattended outside overnight in freezing temperatures.
Anthology of McCandless (Pittsburgh)
2022 (month undisclosed)
Name withheld. The resident was sitting in the sun unattended on a patio.
Luther Ridge at Seiders Hill (Pottsville)
February 2018
Name withheld. The resident went out a door near a loading dock and fell in a driveway.
Evergreen Estates (Lancaster)
October 2019
Name withheld. The resident was found on the ground outside the facility entrance.
Rhode Island
The Post did not find any reported deaths in Rhode Island’s publicly available records.
South Carolina
South Carolina does not make reports available online and provided public records only on facilities where The Post first learned of deaths from media reports.
Palmettos of Bluffton (Okatie)
September 2022
Jack Tribble, 79, was found dead in a swampy area near the facility two weeks after disappearing.
Carolina Gardens at Rock Hill (Rock Hill)
January 2022
Joyce Salts, 80, wandered outside in the cold overnight.
South Dakota
South Dakota does not make reports available online. The state said there were no records of walkaway deaths.
Tennessee
J.B. Knowles Home Assisted Living (Nashville)
February 2021
Michael Walker, 63, was discovered dead on the facility grounds.
Texas
Texas does not make reports available online and asked for more than $700 to provide public records. The Post learned of a death from media reports and independently confirmed it.
Colonial Gardens of Austin (Austin)
November 2022
Paull Patterson, 76, wandered outside and was found dead 10 days later about a half-mile from the facility.
Utah
Utah does not make reports available online and did not respond to The Post’s requests for records. The Post did not find any deaths in media reports.
Vermont
The Post did not find any reported deaths in Vermont’s publicly available records.
Virginia
Sunrise at Reston Town Center (Reston)
January 2019
Ida Wolk, 86, was found by police behind the facility, between a rear wall and a dumpster, in the cold.
Brightview Great Falls (Great Falls)
January 2019
Joan Ackley, 88, went outside on the patio in snowy and icy conditions and was found on the ground a few hours later.
Washington
Fieldstone Memory Care of Puyallup (Puyallup)
June 2021
Jerry Jonas, 78, was left unattended outside the facility after a fire alarm and later found unresponsive.
Normandy Park Senior Living (Burien)
April 2022
Name withheld. The resident got locked outside on a patio and was found dead the next morning.
West Virginia
The Post did not find any reported deaths in West Virginia’s publicly available records.
Wisconsin
Cottages at Meadowlands (Oconto Falls)
March 2022
Garner Sowle, 90, wandered from the facility and was found outside the next morning with cuts on his arms and cold to the touch.
Cottages at Lake Park (Marinette)
March 2023
Ruth Alguire, 76, wandered outside and was found dead in the snow the next morning.
Preston Place (Redgranite)
December 2021
Patsy Linzmeyer, 85, was found in a ditch across the street from a gas station.
Angie Simons, who bought the facility with her husband earlier this year, said they have installed alarms, hired nurses and trained staff. “Our staff is fully aware of how they need to respond to these situations.”
Agape Supportive Living (Milwaukee)
February 2018
Alan Schmitz, 65, walked away from the facility and was struck by a car.
Parkside Manor Assisted Living and Memory Care (Kenosha)
December 2022
Name withheld. The resident, 89, wandered into a courtyard undetected and was found unresponsive seven hours later.
Wyoming
The Post did not find any reported deaths in Wyoming’s publicly available records.
The Washington Post is continuing to report on the assisted-living industry, and we want to know your experiences with elder care, assisted living and dementia care. Tell us about your experience here.
Methodology
The Post examined facility inspection data and incident reports from two-thirds of states and collected news reports from across the country, the first time a news organization has attempted to determine the national scope of wandering incidents and deaths among people living with dementia and other cognitive impairments in assisted-living facilities.
Because 19 states do not allow reports to be downloaded by the public, and Nebraska and D.C. have not released new reports in recent years, the data presented by The Post is certainly an undercount.
To collect its data, The Post wrote computer programs to pull facility rosters and the number of beds available in every state, and to gather more than 160,000 available individual inspection reports since 2018 from the states that posted those reports online.
Using key phrases such as “elope,” “wander” and “missing,” reporters searched for cases where residents had left the facility without staff’s knowledge or had been left outside unattended. They expanded their review into states without online inspection portals by scouring media reports and lawsuits and by filing public information requests with state agencies and local police departments. A second and third round of media searches were done by researchers and reporters to try to provide the public with the most complete accounting of walkaways and walkaway deaths.
The Post’s review included both general assisted-living facilities and the more secure dementia-care units. Many states have different names in their regulations for these facilities. The Post used a review from the National Center for Assisted Living to determine the different titles for assisted-living complexes.
The Post counted deaths involving a resident with Alzheimer’s disease or other cognitive problems who got outside or was left unsupervised outside, including in vehicles. In one case a resident was found in a stairwell. In another, the facility placed the resident in independent living although his contract required assisted-living oversight. The Post’s review was not limited to deaths that led state authorities to cite the facilities, but in 9 of 10 cases, inspectors did issue citations.
To examine states’ oversight of assisted-living facilities, reporters gathered regulations regarding staffing levels, training and reporting requirements from each state. The Post then categorized each state into a tier of regulatory oversight based on benchmarks suggested by experts.
Finally, reporters used data from the American Seniors Housing Association ranking the 50 largest senior-housing owners. Reporters classified the companies on ASHA’s list into general categories of ownership, to understand the business models underlying the assisted-living sector.