Resident #3 left Yonkers Gardens Center for Nursing and Rehab through the main entrance in May 2024, captured on camera footage walking out with three other people who were leaving. The security guard was in view of the front entrance when it happened.
The facility's double doors weren't locked at the time.
Staff didn't realize the resident was missing until a certified nurse aide discovered his absence and alerted supervisors. The facility then called a Code Purple elopement alert and contacted local police. Staff searched the building and surrounding streets before finding him on a nearby corner, sitting on the floor and leaning against a wall.
The resident's family questioned why someone with dementia didn't already have a wander guard device. "Family questioned why the facility didn't already have a wrist band on Resident #3 since he has dementia," according to the inspection report from a September interview.
The facility installed a wrist band monitoring system only after the incident.
During the day before he disappeared, Registered Nurse #13 observed the resident talking with other residents around 4:30 PM and saw him in the dining room at 6:00 PM. The nurse described him as "friendly, fully dressed and talking with other residents" and said he "never mentioned wanting to leave the place."
The resident had never shown signs of wanting to elope before the incident.
His family expressed deep frustration with how the facility handled the situation. They told inspectors they "do not understand why the nursing home took so long to report the incident" and couldn't comprehend why a dementia patient lacked monitoring equipment.
"Family claimed there was no one at the nurse's station or front desk keeping an eye on residents so it was too easy for Resident #3 to leave the facility," the report states.
The family noted a stark change in their relative's behavior since the incident. While he had never eloped or gone missing when living at home with family, he now "expresses a wish to leave this prison." The family told inspectors they are "making plans to bring them back home."
"Family stated that they put Resident #3 in a nursing home to get quality care and because family could no longer look after Resident #3," according to the inspection. They said the facility "needs to pay more attention to their residents or find a new profession."
Nursing Supervisor #10 told inspectors during a September interview that they didn't have "exact recollection of incident." The supervisor described the protocol for missing residents: conduct a head count throughout the facility, send staff to search the immediate area, and contact the resident's physician, local police, and emergency contacts.
The supervisor said reporting incidents to the New York State Department of Health falls under the Director of Nursing's responsibilities.
Administrator interviews revealed the facility's investigation concluded an elopement had occurred. Camera footage confirmed the resident left through the main entrance on May 22, 2025, alongside three other people departing the facility.
The facility made several changes after the incident. They added a lock to the front door, provided additional staff education, and replaced the security guard who was on duty that night. The original security guard worked for an agency and was replaced by a guard from a different agency.
The facility's policies require wander guards for at-risk residents and accountability documents for certified nurse aides to monitor wandering risks each shift. The "Out on Pass" process typically involves team decisions with physician orders, and supervisors or social workers explain the process to families.
But none of these safeguards prevented the 14-hour disappearance.
The family remains "very upset about Resident #3 missing" and frustrated with delays in the facility's investigation, according to their September interview with state inspectors.
Inspectors attempted to reach Security Guard #16 on the day of their visit, leaving messages at 2:51 PM and 3:04 PM. The guard never returned their calls.
The incident resulted in a citation for failing to provide adequate supervision and assistive devices for residents at risk of wandering, with minimal harm noted to few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Yonkers Gardens Center For Nursing and Rehab from 2025-09-16 including all violations, facility responses, and corrective action plans.
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