Late one morning in May 2021, a resident of Cape Elizabeth, Maine, spotted an “elderly, disoriented” man standing in a driveway, according to a police report. The resident called police and then followed the man on foot as he wandered to a nearby intersection.

When police officers arrived, the man had difficulty communicating with them. But he was clutching a toiletry case that contained a card for Cape Memory Care, the residential care facility where he lived.

When the officers brought him back, the facility’s staff said they didn’t know that he had been missing. The officers reported the incident to the Maine Department of Health and Human Services for “inadequate care and supervision of a patient.”

The health department opened an investigation but only conducted a “desk review” — looking into the incident without visiting the facility. Three weeks later, it closed the case without citing Cape Memory Care for failing to prevent the man from wandering away.

The health department’s minimal response to the incident illustrates what happens when residents wander away from their residential care facilities in Maine: In the vast majority of cases, investigators never inspect the facilities, conducting only a desk review or no investigation at all, and rarely impose sanctions.

Maine is the oldest state in the country, where people aged 65 or older make up the highest share of the population. The Maine Monitor and ProPublica reported last year how residential care facilities in the state had been ill-prepared to handle the influx of older Mainers, many with significant medical needs, following the state’s decision in the mid-1990s to make it harder to qualify for nursing home placement.

The number of people in the state with dementia is projected to grow by 20% between 2020 and 2025. And for residents with dementia in residential care facilities, elopement — which the state defines as an incident in which a resident “unsafely wanders” out of a long-term care facility — is a real risk.

From 2020 to 2022, new reporting shows, residents wandered away from Maine residential care facilities at least 115 times, according to state inspection records and a database of incidents reported to the health department.

The incidents took place at 48 residential care facilities classified as Level IV, which resemble what are known generally as assisted living facilities in other states. According to the Maine Department of Professional and Financial Regulation’s online licensing portal, there are roughly 190 Level IV facilities in the state.

The Maine Monitor and ProPublica found that at least 30 of the elopements took place at Cape Memory Care and other facilities that house people with severe dementia — which are required to be locked or otherwise secured to prevent residents from wandering away.

In 98 of the elopements, investigators conducted only a desk review or no investigation at all. Health department spokesperson Lindsay Hammes said investigators decide not to take action for a variety of reasons, including because a facility has already moved to correct the underlying issue.

“The Department takes seriously and investigates instances of elopement. A desk review is one type of investigation,” Hammes said.

Woodlands Senior Living, which runs Cape Memory Care and 13 other Maine facilities, declined to comment on the May 2021 incident.

Eilon Caspi, a gerontologist and assistant research professor at the University of Connecticut’s Institute for Collaboration on Health, Intervention and Policy, said the health department should investigate every time a resident wanders away, even for a brief moment, and impose substantial fines in more serious cases.

The health department “should consider every situation where a resident leaves for a few — even for five seconds — as a serious incident,” Caspi said, “because if staff are not there, then the resident may continue out the door into the road or into a lake or snowbank. … It only takes two minutes.”

From 2020 to 2022, the health department imposed sanctions against only two residential care facilities for failing to prevent their residents from wandering away, state inspection records show. This contrasts sharply with how the federal government responds to elopements at nursing homes. 

Even though the Centers for Medicare and Medicaid Services, which regulates nursing homes, isn’t mandated to impose sanctions, the agency did so in response to at least 11 elopements in Maine that it investigated from February 2021 to February 2024. (CMS couldn’t provide the total number of elopements reported by Maine nursing homes.)

According to a CMS inspection database, the agency imposed a fine of more than $71,000 against one Maine nursing home and issued three additional “immediate jeopardy” citations, which can lead to the facility being prohibited from billing Medicare or Medicaid if deficiencies aren’t corrected.

CMS determined that most of the other elopements resulted in “minimal harm,” but those comparatively minor incidents still led the agency to require the facilities to submit a plan of correction stating how they intended to address the deficiencies.

Under state regulations, the health department does have the power to impose a fine of up to $10,000 or issue a conditional license that bars residential care facilities from accepting new residents for up to 12 months.

But even with the two serious cases that led to sanctions, including one where a resident died, it employed only the lowest level of intervention: requiring the facilities to submit a plan of correction.

In one of the two incidents, in December 2022, a resident at Woodlands Memory Care of Rockland in the state’s Midcoast region died after getting into a locked outdoor courtyard without anyone at the facility noticing for nearly two hours.

The resident was one of the nearly 100 people around the country who have died since 2018 after they wandered away from their assisted living facilities, according to a December investigation by The Washington Post.

But the health department didn’t impose a fine or issue a conditional license after the courtyard incident. Woodlands of Rockland was only required to submit a plan of correction, in which the facility said it would “limit access to the exterior courtyard” with consideration of “weather conditions, time of day, and time of year.”

Woodlands Senior Living, which also runs Woodlands of Rockland, declined to comment further.

The only other sanction imposed in response to elopements was against another Midcoast residential care facility, Frankfort Assisted Living, where a resident was found by a neighbor standing in the middle of a busy road with her walker during a heat wave in August 2022.

Tara Lyford, who lives across the street from the facility, told The Monitor and ProPublica that the resident appeared confused and disoriented as cars zipped by going much faster than the road’s 45 mph speed limit. When Lyford approached, the resident told her that she was trying to hitchhike away from the facility.

According to Lyford, when she brought the woman back, an employee told her that no one had noticed that the woman was missing. The employee also told Lyford — and a state investigation later confirmed — that she was the only one on duty at the time, even though, under state regulations, the facility was supposed to be staffed by at least one more direct-care worker.

Lyford also learned that the facility didn’t have alarms on its doors; that precaution isn’t required by the state because it isn’t a memory care facility. But the whole situation worried her.

“How is that safe?” Lyford said she asked the employee. “I said, ‘You’re the only worker here. You don’t know who’s coming and who’s going. She’s in the road.’”

After investigating the incident, the health department issued a “statement of deficiencies” against the facility, saying it “caused the resident to be at risk for physical harm and injury when the resident wandered outdoors on the road alone, confused, and disoriented.”

The health department could have imposed a fine or issued a conditional license but it only required the facility to submit a plan of correction.

The facility’s parent company, Texas-based Magnolia Assisted Living, told The Monitor and ProPublica that the incident took place days after the company purchased the facility.

“There were significant issues at the time of acquisition and we immediately tried to address each of the issues,” Edward Sedacca, CEO and founder of Magnolia Assisted Living, said in an email. “All of the initial staff of the Frankfort property have been replaced as part of an overall effort to improve the property.”

In its plan of correction, the facility told the health department that it would train its employees on “observation of residents with potential elopement issues” and ensure “continuous observation of residents.”

Dr. Karen Saylor, a Falmouth-based geriatrician who works with residents at several Level IV facilities, said the incident was “alarming” and highlights the need for the state to make sure that people with dementia are promptly moved to nursing homes or memory care facilities when their conditions worsen.

“If you have somebody who is that confused that they’re standing in the middle of traffic, that’s a hard stop,” Saylor said. “They need to not be there. That is not the right place for them.”

But Sedacca said the shortage of beds funded by MaineCare, the state’s version of Medicaid, means that it can take months to move people with dementia to nursing homes or memory care facilities.

“Many Assisted Living properties cannot accommodate residents with dementia and cognitive disorders that are exit-seeking or elopement risks,” Sedacca said. Further complicating matters, he said, is that MaineCare’s rules don’t allow facilities to hold residents who aren’t in memory care against their will or to physically keep them from leaving.

Long-term care advocates say it’s ultimately the responsibility of each residential care facility to make sure that it has the capacity to meet the needs of all of its residents.

”If a care home is going to take care of people living with dementia, they have a moral, if not regulatory, obligation to know what they’re doing,” said Susan Wehry, who directs AgingME, a program at the University of New England in Biddeford, Maine, that trains health care workers, patients and their families to improve health outcomes for older adults.

Hammes, the health department spokesperson, said residential care facilities are expected to adjust how they care for residents who start showing the signs of dementia. Facilities could, for instance, put an ankle monitor on or closely monitor the habits of those who have a tendency to wander away.

Hammes added that residential care facilities must also ensure that they have sufficient staff to meet the needs of their residents.

But even some providers say the state isn’t doing enough to make sure that residential care facilities are living up to expectations. Nichole Lessard, the co-owner of Heron House, a Level IV facility north of Portland, said the state’s staffing requirement is particularly lacking, calling it “scary,” “unsafe” and “completely inadequate.”

Currently, residential care facilities with more than 10 beds are required to have one direct-care worker for every 12 residents during the day, one for every 18 residents in the evening and one for every 30 residents overnight.

Even though Heron House isn’t a memory care facility, Lessard said about 95% of its residents have memory issues, so she ensures that it has almost twice the required number of staff. She said that’s what it takes to keep residents from wandering away.

“If you’re going to take care of people with more memory care needs, then you’re going to need to be able to staff for those behaviors that come with it,” Lessard said.

Lessard added that the state’s dementia training requirement is also woefully inadequate. Currently, non-memory-care facilities aren’t required to provide any dementia training. Memory care facilities, meanwhile, are mandated to provide a one-time dementia training — but not ongoing training, which is required for nursing homes.

Pat Sprigg, who served as the CEO of a North Carolina retirement community called Carol Woods for 30 years, said it’s important for all long-term care facilities to make sure they have well-trained staff.

Sprigg, who is writing a book about how to care for people with dementia without restricting the freedom of their movement, said not educating staff about memory care means that “you’re going to have people walking out of your community all the time.”

During this year’s legislative session, state Rep. Margaret Craven, a Democrat who represents the city of Lewiston and serves on the health and human services committee, introduced a bill calling for the establishment of a dementia advisory council that would recommend a state plan to better meet the needs of people with Alzheimer’s disease and other memory issues.

Craven told The Monitor and ProPublica that she would support having higher staffing requirements and more dementia training as part of the state plan “because people, in my opinion, are not adequately taken care of.”

In May, the Legislature passed Craven’s proposal, but Gov. Janet Mills’ office said she isn’t signing that bill or 34 others based on a technicality: Lawmakers approved the measures on a day when they were supposed to only consider overriding vetoes.

Craven said she was disappointed but not giving up, even though she isn’t running for reelection and won’t return to the Legislature for the next session. “I’ll have someone refile the same bill next year,” she said.