The September 6 incident marked the latest in a series of escape attempts by the resident, who had been placed on every-two-hour monitoring because of his repeated efforts to leave the facility.
Federal inspectors found the facility failed to prevent the resident from wandering into traffic, creating immediate jeopardy to his safety.
The resident had lived independently on the nursing home campus until his family moved him to the skilled nursing facility due to declining cognition. His wife also lived at the facility, and his family had strongly resisted the facility's recommendation to transfer him to the locked memory care unit because they wanted the couple to remain near each other.
Family members told inspectors they had hired a private sitter to watch the resident around the clock starting July 22, but gradually reduced the supervision to just four hours daily beginning September 1.
"Resident #1 was very strong-willed and was confused as to why he could not leave the facility as he typically did prior to admission," family members explained to inspectors during a September 10 interview.
The escape occurred when the dietary manager unlocked the double doors leading to the conference room that morning, then went to work in the kitchen. The doors were typically locked on weekends.
Assistant Director of Nursing told inspectors that Nurse #1 notified her the resident "had gone out of the conference room door and they were notified by the Police Department that he was on the main road outside of the facility campus."
The resident was alert when found but had visible injuries. He was transported to the hospital for evaluation, accompanied by the Director of Nursing.
The facility had discussed the resident's elopement risk extensively with his family since his admission. His family explained that before entering the nursing home, he had lived independently but was becoming increasingly forgetful, including leaving his coffee pot on during the day.
"Family Member #1 stated she did not feel comfortable with him living alone so the family decided to place him in a more assisted environment," according to the inspection report.
The dietary manager was in the kitchen during the incident and did not see the resident walk past the unlocked doors and exit the building.
Federal inspectors determined the facility failed to provide adequate supervision for a resident with known elopement risks, despite his history of multiple escape attempts and the family's investment in private sitters to prevent exactly this scenario.
The resident's confusion about his confinement stemmed from his previous independence on the same campus. His strong will and determination to leave, combined with unlocked exit doors and inadequate monitoring, created the dangerous situation that ended with police finding him on a public road.
The inspection revealed the facility had recognized the elopement risk serious enough to recommend transferring the resident to a locked unit, but had not implemented sufficient safeguards when the family declined that placement to keep him near his spouse.
The case illustrates the challenge nursing homes face balancing family preferences with resident safety, particularly for dementia patients who retain physical strength and determination while losing cognitive awareness of danger.
The resident's injuries from his roadside discovery underscore the potential consequences when facilities fail to secure exits for residents with documented wandering behaviors and cognitive impairment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Stewart Health Center from 2025-09-23 including all violations, facility responses, and corrective action plans.