A Wisconsin memory care community has been fined $4,200 and is prohibited from accepting new residents after a resident with dementia wandered outside and froze to death in December.

The state Department of Health Services, in a January survey report made public Monday, said that 84-year-old resident Alice McGaw (not named in the report but named in the media) was able to leave Faith Gardens in Sun Prairie, WI, in the early morning of Dec. 29 because a front-door alarm wasn’t activated, an interior door was propped open or was stuck in an open position because of a rug, and staff members didn’t check on her frequently enough. Also, although McGaw’s care plan stated that she should wear an alarm bracelet, the community didn’t use such a system, the state report said.

McGaw, who moved to the community in October, had been identified as a wanderer, including at the community where she previously had lived, and had tried to exit the building several times before, according to surveyors.

In a Jan. 23 letter, the state listed fines for the community of $2,700 related to not checking on McGaw at least every hour, $1,000 for not using alarms and $500 for not adequately managing her dementia-related behaviors.

Faith Gardens is prohibited from accepting new residents until all violations have been corrected, the letter said.

A nurse told a surveyor in January that since McGaw’s death, managers had started to review and revise the community’s policies and procedures, creating a binder that contained the names of identified wanderers, developing an elopement assessment tool and seeking to upgrade the community door alarm monitoring systems.

Faith Gardens previously told local media that it cooperated with authorities and investigators and also conducted an internal investigation. The community also extended sympathies to McGaw’s family.