Hillside Manor: Elopement Failures Put Resident at Risk - IN
Hillside Manor Nursing Home sits on East National Highway in Washington, Indiana. The courtyard off its common area is accessible through two unlocked double doors near the nurses' station. A gazebo sits inside that courtyard, roughly two feet from a concrete perimeter wall standing about 66 inches tall. That combination, gazebo close enough to the wall to serve as a ladder, unlocked doors, no keypad, turned a walled enclosure into an exit route for a resident the facility already knew was at risk for elopement.
The first escape was July 23, 2025. Emergency medical technicians had arrived at the facility to transport Resident C to a hospital. The resident was frightened by the EMTs. He climbed the gazebo, jumped the wall, and left the property. Staff apparently treated it as an isolated reaction to a stressful situation. The gazebo stayed where it was. The care plan was not updated with new interventions. The wall remained at the same height.
Five weeks later, on August 30, EMTs came again. This time they were there for a different resident. The nurse on duty was in that resident's room, helping manage the EMS transfer. Another resident came to alert her: Resident C had climbed the gazebo again, cleared the wall, and run east.
By the time police received the call, at 6:59 p.m., Resident C was already off the property and moving. Fifteen minutes later, at 7:14 p.m., someone spotted him near Highway 57, adjacent to a vape store. At 7:25 p.m., a law enforcement officer found him hiding behind an air conditioning unit between the store and a neighboring building.
The police report described what happened next in plain terms: "I located the male subject hiding behind an AC unit. He was behind the vape store between buildings. The male subject ran, and I gave chase. He was apprehended prior to running into traffic on National Highway."
He had been outside the facility for approximately one hour.
Inspectors visited the facility on September 3, five days after the incident. They walked the courtyard themselves. The gazebo was still there, still roughly two feet from the wall. The wall was still 66 inches. The double doors leading from the common area were still unlocked, no keypad required. Nothing about the physical environment had changed in the days following the second elopement.
A qualified medication aide, identified in the report as QMA 5, told inspectors that Resident C had jumped the wall on both occasions after being frightened by EMTs. She confirmed the July incident and the August incident. She said the resident feared the EMTs.
The Director of Nursing confirmed both escapes to inspectors and acknowledged what the facility's own policy required: if a resident at risk for elopement began showing increased exit-seeking behaviors, the care plan should be updated with new interventions. An elopement risk assessment, she said, should be completed quarterly, and any time a resident shows increased exit-seeking behavior.
The July 23 escape was an increase in exit-seeking behavior. It was not a first offense, either. Resident C had been flagged as at risk for elopement after an incident in April 2024. Then, in June 2025, he left the facility by himself to walk to a fast-food restaurant. Staff knew where he was going and believed he was capable of making the trip alone. Whether that judgment was reasonable or not, it meant that by the time July 23 arrived, there was a documented history: a 2024 elopement risk flag, a June 2025 solo restaurant walk, and then a courtyard wall jump. Three escalating data points. The care plan was not updated after any of them.
Federal inspectors cited Hillside Manor at the Immediate Jeopardy level, the most serious classification available under the inspection system, meaning the deficient practice had placed residents in a situation likely to cause serious injury, harm, or death. The citation covered a few residents rather than the full population, but the physical hazard, a climbable gazebo two feet from an exterior wall, was available to anyone who walked through those unlocked double doors.
The facility moved to resolve the Immediate Jeopardy finding by September 5. It removed the gazebo from the courtyard. It also took down a tree and secured the patio furniture. All exit doors were equipped with Wander-Guard keypads. Staff received in-service training on the elopement and exit-seeking policy. The facility completed audits of clinical records for all residents identified as at risk for exit-seeking behavior or elopement.
Inspectors accepted those steps. The Immediate Jeopardy designation was lifted on September 5 at 11:20 a.m. The underlying deficiency remained on the record at a lower severity level, characterized as isolated, no actual harm, but with potential for more than minimal harm.
No actual harm. That is the formal designation. Resident C was outside for an hour. A police officer chased him on foot and stopped him before he ran into traffic on a state highway.
The inspection report does not describe Resident C's diagnosis, his age, or what he was doing in a nursing home. It does not say whether he understood where he was or where he was going when he ran. It says he was frightened by EMTs. It says he hid behind an air conditioning unit. It says he ran when he heard the officer.
What the record shows is that the facility knew this resident could elope under specific, predictable conditions. EMTs had arrived twice. Twice he climbed the same structure and cleared the same wall. The conditions that triggered the first escape were documented. The physical feature that made it possible was left in place. When the same conditions recurred five weeks later, the outcome was the same, except this time a police officer had to run him down before he reached the highway.
The gazebo has since been removed. The keypads are installed. The staff have been trained. The courtyard is, by the facility's account, now secured.
Resident C is still there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillside Manor Nursing Home from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
HILLSIDE MANOR NURSING HOME in WASHINGTON, IN was cited for violations during a health inspection on September 8, 2025.
Hillside Manor Nursing Home sits on East National Highway in Washington, Indiana.
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.