According to the 7/19/2021 Medicare report, inspectors found that two residents identified as elopement risks were not properly supervised to ensure their and other residents’ safety. Neither resident was given a Wanderguard device to help monitor and prevent elopement. On several occasions, one resident was found pacing the hallway and entering other residents’ rooms, clearly agitated. On more than one occasion, both residents were able to leave the facility. These elopement events involved climbing gates and crossing busy roads where the residents could have been hurt.