Three days after Carl “Jack” Johnson moved into Saxon Personal Care Home last November, police were called for help.
The 76-year-old, who suffered from dementia, had wandered away, but he was soon found about 600 feet from the Augusta facility.
The incident should have been a warning for the 18-bed home to better monitor its vulnerable resident. Instead, it served as dark foreshadowing.
Credit: Courtesy of Rick Sams
Credit: Courtesy of Rick Sams
Two weeks later, on the night after Thanksgiving, Johnson went missing again. This time the facility didn’t call police, but law enforcement still got a call — when they were alerted to an accident.
Johnson’s body was face-down on Mike Padgett Highway after he was punted 64 feet by a vehicle, according to the state’s crash report. A victim of a hit-and-run, he was pronounced dead just before midnight. He was nearly 2 miles from Saxon, and video later discovered indicated he had been missing at least three hours.
“It all played out pretty bad,” said Johnson’s stepson, Richard Sams, who awoke to two missed calls from the facility alerting him to the death.
“He didn’t even know what hit him,” Sams said.
Since January 2023, at least two other Georgia seniors have died after wandering off from long-term care homes. The most recent victim: an 89-year-old who went missing from a Marietta assisted living facility earlier this month, only to be discovered dead, days later, in a nearby pond.
Yet these incidents, which the state calls “elopements,” only scratch the surface of the problem.
An Atlanta Journal-Constitution investigation has found that between January 2023 and July 2024, at least 58 elderly people, many of them suffering from dementia, wandered away from Georgia assisted living or personal care homes. The finding, discovered through the analysis of state inspection reports, gives the most comprehensive figure to date behind this underreported issue and highlights the extreme risks when senior care homes fail one of their most essential responsibilities: not losing their residents.
And while some of the incidents had outcomes similar to Johnson’s first disappearance — a quick find and return — many were not so easily resolved. Inspection reports reviewed by the AJC highlight instances of injuries, cases in which residents were out in the cold at night for hours, and incidents where the missing were never found.
The reasons: a lack of alarms, unlocked exit doors in memory care units and not enough working staff, to name a few.
Exacerbating this issue is the state’s response. It doesn’t treat all elopements with the acknowledgment of the severity — and finality — that they can have. The AJC has found that in at least three dozen cases, the Georgia Department of Community Health investigated an elopement, confirmed that it happened after rules were broken, and then ranked the violations with the lowest possible violation tag: a D, which carries zero financial penalties.
In one incident in June, a resident known as a flight risk wandered out of a memory care unit northeast of Atlanta and fell, hitting their head on concrete. A state review resulted in a D-level violation with no fine. At another suburban Atlanta memory care facility this March, a resident who repeatedly wandered away was discovered in the middle of a four-lane highway. A staff member told the state inspector that other staff should have supervised the resident but did not. Conclusion: a D-tag with no fine.
When asked to comment on these specific incidents, DCH spokesperson Fiona Roberts referred the AJC to the department’s violation rubric, known as the matrix.
“Each individual complaint investigation/compliance review considers all facts and variables that contributed to an outcome which may impact the writing of a deficiency as well as the severity level,” Roberts wrote in an email.
She later added that she had no additional information to provide about the AJC’s findings that there were at least 58 elopements between January 2023 and July 2024.
When violations have been deemed as more severe, the state has been open to cushioning the repercussions with settlement agreements, the AJC found. This not only blunts the deterrent effect, said Melanie McNeil, Georgia’s long-term care ombudsman, but also flies in the face of the state’s 2020 reforms, which promised facilities would be fined at least $5,000 for infractions that caused a resident to be seriously harmed or to die.
The focus of regulators across the country is on getting facilities to fix the underlying problems, McNeil said. She was happy to see the legislation pass but is frustrated to see some of the same problems persist.
“We want the fines to sting enough that they’ll stop doing the bad stuff,” she said. “If the fines aren’t significant, it just becomes the cost of doing business. You just build that into your budget.”
Nowhere is the state’s blunted approach more clear than in Johnson’s death.
Although Sams reported the painful episode to the state last fall via a complaint, it wasn’t until the AJC reached out in September that he learned the state had given Saxon a remarkable deal.
In a settlement agreement reached in June after Saxon contested DCH’s proposed $6,003 fine, the state offered Saxon a 50% reduction in the penalty. The home’s operators were told they owed only $3,000, to be paid over a year — which works out to $250 a month, significantly less than the $1,191 Johnson had agreed to pay each month for room and board.
“Why did the state agency just give them a little slap on the hands and say, ‘OK, carry on,’” asked Sams, notably disturbed and confused by the news.
Roberts said DCH couldn’t comment on specific cases when asked about the decision to enter into a settlement agreement with Saxon, simply referring the AJC to a previous answer she had given about such agreements. She noted the department and its legal team have the “authority to reduce, settle, negotiate any fine amount, and many factors are included in these decisions.”
Saxon did not respond to requests for comment.
For Sams, there is little resolution.
“How can they not shut down a place that was evidently not providing adequate care? And a person died as a result, died a violent, tragic death,” Sams said. “I don’t understand. Why would the state do that?”
Two more deaths this year
Questions like Sams’ plague many elopement cases. The scant information available to the public rarely provides the answers, as seen in the deaths of two other long-term care residents this year.
When Patricia Miele went missing earlier this month from Greenwood Place Assisted Living and Memory Care in Marietta, police were notified just after 9:30 a.m. on a Saturday. But police reports say she was last seen at 11 p.m. the night before. What happened to the 89-year-old during those unaccounted for hours? State law requires homes to alert law enforcement within 30 minutes of realizing a disabled resident cannot be located. When did staff realize Miele was gone?
Greenwood Place did not respond to the AJC’s questions about the gap in time.
When the missing person notice did eventually go out, the description of Miele struck a nerve in the community. Gray haired and smiling in the photo, she was described as being hearing impaired and showing recent signs of confusion. The notice stated she was last seen wearing a purple floral shirt, blue jeans and slip-on Sketcher shoes. Wherever she may have gone, she didn’t take her glasses with her.
Credit: Marietta Police Department
Credit: Marietta Police Department
Over the next 48 hours, the Atlanta suburb kicked into high gear searching for Miele. Multiple agencies joined in the search. TV stations were asked to get the word out. Her missing person poster was shared on Facebook over and over again.
“We’re a town of 70 to 80,000, but you’d think we were a town of 2,000. People really rallied hard and fast,” Marietta police spokesman Officer Chuck McPhilamy said Monday morning, as the search continued.
Hours later, a couple made a gruesome discovery: Miele’s body in a pond, about half a mile from the residence.
“In Mrs. Miele, we saw our own mothers and grandmothers, and we wanted nothing more than to find her safely and return her to you. While that wasn’t the outcome, know that our efforts were genuine, thorough, and led by a servant’s heart. You will be in our thoughts and prayers during this difficult time,” Marietta Police Chief David Beam wrote in a statement posted on social media after the discovery.
How could she leave without Greenwood staff noticing? Was a caregiver making rounds at night?
Diana Ferrante Thies, a senior vice president at Greenwood, said that door systems and alarms were working properly and that community protocols were followed upon learning Miele was gone.
But she stressed in a written statement to the AJC that the 89-year-old was in the assisted living portion of the complex, not in the memory care side. A care option in assisted living includes the ability to come and go, she wrote in an email.
Credit: Hyosub Shin/AJC
Credit: Hyosub Shin/AJC
She otherwise would not get into specifics about Miele’s case, citing the confidentiality and integrity of the investigation and privacy of the residents, staff members and family involved.
Earlier this year, a DCH review and a police report of other incidents detailed concerns that Greenwood didn’t have enough staffing to meet residents’ needs, an issue all too common in senior care facilities.
In April, DCH inspectors found the home didn’t have enough staff working, and for several hours no medication aide or nurse was in the memory care unit, a violation of state law. The various staffing issues were ultimately tied to four violations — all ranked as D’s.
Then in September, a resident’s son called police, saying he wanted to “document the situation which he described as unacceptable living conditions for his relative,” according to the report. The home’s caregivers were having to work 15- to 16-hour shifts to keep up with residents’ needs amid worker shortages, the report says. And the home had no cook on staff, the son said, so residents were being fed ordered-in pizza and IHOP meals.
Others echoed his concerns, the police report shows. But the director of Greenwood’s memory care unit told police that the home was exceeding state staffing requirements.
It’s unclear if DCH was notified of the concerns reported to police. It didn’t post any September or October inspection reports on the home. A November complaint investigation found no violations, a report shows.
Greenwood did not respond to questions about the staffing issues.
DCH did not answer questions about Miele’s disappearance. Roberts, the spokesperson, said the state couldn’t comment on an open investigation.
Credit: Monroe Police Dept.
Credit: Monroe Police Dept.
Questions also still remain after 63-year-old John Brock, who suffered from epilepsy, depression and schizophrenia and had episodes of memory loss, wandered away from Petal’s Personal Care Home, a small personal care facility in Monroe, on Feb. 19.
It was cold that night, and colder the next, with temperatures dropping to the 20s, a particular threat to a man who was only 5′5″ and weighed just 115 pounds.
Nearly 10 days later, law enforcement discovered his body covered in heavy brush by a ravine nearly 3 miles from the home. According to his death certificate, he died of “probable environmental hypothermia” due to the cold weather.
In March, DCH completed a report of the incident. Among its findings: Brock had been gone 11 hours before staff at Petal’s noticed; chimes on the exit doors weren’t working; and the home didn’t have an awake caregiver at night. DCH levied a fine of $1,201, which Petal’s paid in July.
DCH wouldn’t explain why a fine of a little over $1,000 was imposed, when the state law enacted in 2021 mandates a fine of $5,000 for violations that result in death.
“We cannot comment on the individual case as noted above, but when determining a fine, legal has to assess each case individually as to whether we can prove the nexus exists between causation (whether the act of the facility caused the death of the resident),” Roberts wrote. “We have to assess whether the sufficient evidence exist(s) to prove it in court.”
It’s unclear if the state has ever levied the $5,000 fine. Roberts would not answer the question directly. Instead, she referred the AJC to documents it received via an Open Records Act request listing fines. But the document doesn’t show the violations tied to the fines.
Just as puzzling are cases where residents went missing and DCH found violations, but none were deemed worthy of a fine.
Among the cases detailed in reports reviewed by the AJC:
- A resident known to be an elopement and fall risk wandered off from a facility east of Milledgeville while the staff was prepping dinner. Crossing a street, the resident tripped on a curb, suffering a knot to the forehead, cuts and bruises. A hospital diagnosed the resident with traumatic brain injury and bleeding around the brain.
- At another home in South Georgia, a memory care resident who had already eloped twice wandered away again, spending 10 minutes walking along the edge of a major highway.
- During a chilly week in February, a resident with dementia wandered away from a West Cobb memory care unit, dressed in shorts and a polo shirt. The resident was found after knocking on the door of a fire station.
Safeguards lacking
Johnson was lost and killed so quickly that his death didn’t garner the public attention given to Miele’s and Brock’s disappearances. News reports didn’t even mention he had been lost by a personal care home, instead focusing on the hit-and-run aspect of the tragedy.
When DCH did go to investigate the home, completing a report weeks later, it found that on the night Johnson died, caregivers didn’t discover he was missing until between 10 and 10:30 p.m. — an hour after a surveillance camera recorded him at Dollar General buying snacks.
Instead of calling police when staff realized Johnson was gone, they decided to do another round of checks. When he was still missing at 11 p.m., two staffers left to search for Johnson, according to a subsequent state report. As they were driving, they approached a rush of sirens and flashing red and blue lights: the crime scene.
According to Sams, after the first time his stepdad went missing, Saxon had said it would get alarms for his door, but the home ultimately disabled them because they were constantly buzzing every time Johnson went in and out of his room.
This detail was somewhat confirmed in a state report. It noted a staffer told the state inspector that the resident often wandered away, and staff needed to supervise him more often. The alarms that they had to help with this were not working, the staffer told the state.
It’s a detail that Sams holds on to, as he acknowledges that the industry is also a difficult one and deals with vulnerable, high-need populations. But it’s also not a reason to shirk safety measures, he said.
“Bad things happen. There are difficult circumstances,” he said, “But you don’t just let someone wander off and bypass the things that were supposed to be put in place to keep them safe because they were annoying.”
The state’s Dec. 11 report cited Saxon for failing to call police within 30 minutes after realizing Johnson was lost; failing to have alarms on his door; being understaffed the night he went missing; and having a person on staff who wasn’t properly trained.
A subsequent letter notified Saxon of a $3,603 fine for these violations.
The home immediately contested the fine, and in January DCH and Saxon engaged in settlement talks.
When those were unsuccessful, the state pushed for a judge to make a decision in its favor, and adding pressure to the situation it sent the home a second inspection report with associated fines totaling $2,400. These were based on a number of violations involving administrative issues found in a Dec. 20 inspection report.
This raised pending fines to $6,003.
Then three months later, DCH inked its settlement agreement, lowering the fine to $3,000 to be paid over a year’s time.
“You’re the first person who told me that they settled. I didn’t hear that. Nobody’s ever told me that,” Sams told the AJC.
Saxon’s first payment was due on Aug. 26. It should have paid $750 by now. Payment data received by the AJC via an Open Records Act request shows that as of mid-October, it had yet to write a check.
This spring, after Sams followed up with DCH about the findings of his complaint, he was sent a letter stating a review had been completed. Evidence obtained during the investigation was “able to support one or more of your allegation(s),” according to the April 9 letter from an interim regional director of DCH’s personal care home program.
“Thank you for sharing your concerns with us. Please be assured that we will continue to hold this facility accountable for providing safe care,” the letter states.
The correspondence did not, however, share what allegations were substantiated, or what the state planned to do as a result. When Sams called to inquire, he was sent related inspection reports. The reports — clearly stating ways the home had violated state law — made Sams believe justice was being served and the home had been found “culpable.”
The state representative who he spoke with told him that the case would be going before a judge, referring to the administrative court process that is triggered when homes contest fines. He was asked if he would be willing to testify, to which he said of course.
Sams was still waiting to hear back from the state about the court date when the AJC got in touch.
“I never heard from them again,” he said.
Roberts said that DCH doesn’t have any requirements under current law for reporting fines or settlement agreements to “external parties.”
DCH, she wrote in an email, “also does not discuss legal matters with parties outside of settlement agreements.”
Last week was the one-year anniversary of Johnson’s death. And while his absence is felt by his family, little else has changed.
A view of Saxon’s website would tell visitors nothing of what transpired last fall.
“Saxon PCH has been in business for over 20 years and has maintained a stellar record of resident satisfaction,” the website reads, touting at the top that it provides “24 hour care.”
Credit: Courtesy of Rick Sams
Credit: Courtesy of Rick Sams
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