The family of a deceased former senior living community resident is suing the Michigan community where she lived, claiming negligence and carelessness because she eloped and died from hypothermia. The lawsuit was filed Jan. 12.

Kathryn Brackett, 85, was last seen in her room at Crystal Springs Peace Harbor, an assisted living and memory care community in Grand Rapids, MI, at approximately 12:30 a.m. on Oct. 26, and her body was found in the community’s courtyard the next day at 5:20 a.m., according to staff member interviews conducted by the Michigan Department of Licensing and Regulatory Affairs. LARA’s report, dated Dec. 6, refers to Brackett as “Resident A,” but she is named in the lawsuit.

Brackett had dementia and had moved into the community in late August 2016, according to the report. Staff members told investigators that Brackett’s assessment plan identified her as an elopement risk because of her dementia, not based on a history of behavior. Brackett’s son, however, told investigators that the community knew of previous attempts by his mother to elope at home, at a rehabilitation facility and at Crystal Springs.

The state investigation found that the community usually checks on residents every 30 minutes, but a lack of communication on Oct. 27 resulted in some staff members assuming that others had performed checks that did not occur. Doors at the community have alarms, but interviewed staff members said they only heard one alarm overnight, when another resident opened a door to look outside. The LARA report cited speculation by the Kent County Sheriff’s Department that Brackett could have left the building through a different door at the same time as the other resident and that the alarms could have gone off simultaneously.

LARA found Crystal Springs to be in violation of its license by not providing supervision, protection and personal care as defined by law and as specified in Brackett’s written assessment plan. The community was ordered to provide a plan of correction before being issued a six-month provisional license.

Meridian Senior Living, which operates Crystal Springs, declined to comment to the media.