GEORGETOWN TOWNSHIP, Mich. (WOOD) — A state investigation into the death of an 83-year-old man outside a Jenison adult foster care home shows he had been left outside in the cold for more than seven hours, and that staff admitted they had failed to check on him as required.

The man’s “protection and safety was not attended to and likely led to his demise,” according to a state report released on Saturday.

In an unusual move, the state investigator recommended revoking the license of the 20-bed home, American House Jenison Cherrywood.

“Due to the severity of the violations, disciplinary action against the license is recommended,” the state investigator wrote.

Calvin Powers was found dead outside the home on Oct. 14. The report shows it was 49 degrees and raining and that Powers was wearing pajama bottoms and a hunting jacket.

Powers had pulled a fire alarm at 7 the night before, then walked out the front door unnoticed. A review of surveillance video shows he walked out at 7:18 p.m.

His body was discovered at 2:19 a.m. the next day in the grass just outside the home, about 25 feet from his walker.

An Ottawa County sheriff’s detective told the state that the home’s nursing manager “informed him that staff have not been doing routine checks on residents,” according to the report.

The home knew he was a risk of walking away, the report shows. He’d been living in another adult foster care home in the same complex when he walked away less than two weeks earlier.

Powers was moved to the Cherrywood home the next day because it is a memory care facility with doors that lock from the inside.

The regional vice president of American House told the state that the door’s alarm didn’t sound because the pull station on the wall wasn’t reset after the fire alarm went off.

Powers reportedly had suffered delusions and hallucinations that “led him to looking for an unknown baby and/or his mother,” according to the report.

It was just two days before he died that Powers had become a hospice patient.

The violation was one of five issued to the home after the death. The state also cited the home for being understaffed — having only one worker on duty at night even though some residents require two people to lift them.

It also found that the worker on duty that night had not been properly trained.

“If (she) had been trained, she would have known how to reset the pull station and the door alarm would have triggered” when Powers walked away, the report states.

The state licenses the home to provide 24-hour “supervision, protection and personal care” to the elderly, physically impaired and those with Alzheimer’s. It is required to maintain two workers per 20 residents during sleeping hours.

The home is one of 18 adult foster care homes operated by American House in Kent and Ottawa counties. Seven of the 18 have now been cited for understaffing over the last two years.

It also operates a much larger home for the aged, American House Wyoming, which was cited for being understaffed two years ago.

The death was the second in a little more than a year involving a resident who walked away unnoticed from an American House adult foster care home.

Jean Bruin, 86, who suffered with late-onset dementia, wandered away from American House Cobbleston Kentwood on June 2, 2022. She drowned in a pond near the side door.

The state report said alarms on exit doors were “either inoperable or disengaged.”