Adroit Care Rehab: Elopement Unreported to State - NJ
The resident, identified in inspection records only as Resident 1, had been diagnosed with vascular dementia and mood disorder and had a cognitive assessment score of 12 out of 15, placing them in the moderately impaired range. At 3:10 p.m. that Friday, a nurse spotted the resident in the hallway, well dressed and holding a cellphone. Five minutes later, the resident said they wanted to sit outside. The nurse said okay and went to get a physician's order for an out-on-pass.
The resident did not wait.
By the time police found them, they were away from the building. Officers brought the resident to the precinct. While there, the resident lost consciousness, and staff had to transfer them to an emergency room for evaluation.
The facility's own investigation, contained in an undated report reviewed by inspectors, described what followed: the resident was returned to the facility later that evening, a body check showed no injuries, and a wander guard was placed on the resident going forward. The care plan was updated. The report concluded that because the resident had signed an out-on-pass form and a physician's order had been obtained, the incident was essentially a voluntary walk.
There was one problem with that conclusion. A review of the medical record found no physician's order for the resident to go out unescorted at the time the resident walked away. The order the facility pointed to did not exist in the chart when it needed to.
When inspectors interviewed the Licensed Nursing Home Administrator and Director of Nursing on August 29, the DON said the facility had decided reporting to the state was not necessary. The reason given: they had a physician's order and a signed out-on-pass form.
The facility's own written policy, dated June 5, 2025, said otherwise. Under the heading "Reportable Events," the policy required that investigation results be reported to state agencies within five working days of the incident, with corrective action documented. The elopement happened on August 22. Inspectors arrived on August 29. No report had been filed.
This was not a close call about definitions. A resident with moderate cognitive impairment, diagnosed with a condition that directly affects memory and judgment, left a secured care setting without staff escort, was located by police, and required emergency medical treatment after losing consciousness in custody. The facility's own internal policy and New Jersey state regulations required that to be reported.
Instead, the facility wrote an internal report, added a wander guard, updated the care plan, and moved on.
The inspection, which covered complaints filed under two separate case numbers, found the unreported elopement affected one of three residents whose records were reviewed. Inspectors rated the harm level as minimal harm or potential for actual harm, the lower end of the severity scale, though the resident did require emergency room evaluation following the loss of consciousness at the precinct.
Adroit Care Rehabilitation and Nursing Center operates at 1777 Lawrence Street in Rahway. The inspection was completed September 2, 2025.
What the facility's report called a resident who "verbalized desire to go for a walk" and returned safely that evening left out the part in the middle: the police, the precinct, the loss of consciousness, the ambulance. The nursing home's account of the incident was not false, exactly. It just stopped before the part that required a phone call to the state.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adroit Care Rehabilitation and Nursing Center from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ADROIT CARE REHABILITATION AND NURSING CENTER in RAHWAY, NJ was cited for violations during a health inspection on September 2, 2025.
that Friday, a nurse spotted the resident in the hallway, well dressed and holding a cellphone.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.