The resident had been there "a while" when officers called the nursing home, according to federal inspection records. Staff assisted the person back into their wheelchair and into the facility.
Two days earlier, the same resident had walked out the front door without their assistive device at 9:39 AM. Staff educated the resident about signing out when leaving, but no incident report was filed.
The facility's Director of Nursing confirmed during a September 23rd interview that both incidents met the definition of elopement. Yet administrators filed an incident report only for the September 20th episode when police were involved.
"The DON confirmed that an incident report and investigation was not completed for elopement when Resident 1 exited the facility on 09/18/2025 with out signing out or staff knowledge," inspectors wrote. "The DON confirmed that this incident met the definition of elopement and should have been completed."
The nursing home had developed a care plan on September 19th specifically addressing the resident's desire to go outside unaccompanied. The plan required the resident to sign out when exiting, mandated staff education about telling personnel their destination, and called for staff to safely assist the resident through doors to their desired location.
None of these interventions prevented the resident from leaving undetected the next morning.
Federal inspectors found that facility administrators failed to notify Adult Protective Services, the state regulatory agency, or even their own administrator about either elopement incident. The Director of Nursing acknowledged the facility's policy was not followed.
A facility document titled "Incidents by Incident Type" showed no elopement record for the September 18th incident, despite the Director of Nursing's admission that it qualified as elopement requiring documentation and investigation.
The resident's care plan interventions, implemented just one day before the 3:59 AM police discovery, included educating the resident "on the importance of telling them where they wished to go." Yet the resident left without notification on both documented occasions.
Progress notes show staff documented the September 18th exit and provided education about signing out. But the facility's own incident tracking system contains no record of the episode, and no investigation was conducted despite the resident leaving without their required assistive devices.
The September 20th incident occurred in the early morning hours when the resident again departed without their walker or wheelchair. Police found them sitting in the road in front of the building and had to call the facility to report the situation.
Federal inspectors cited the facility for failing to ensure residents received proper supervision and assistive services. The violation carries minimal harm designation but affects few residents, according to the inspection report.
The nursing home is disputing the citation.
The inspection was conducted September 24th in response to a complaint. The facility operates as The Birch at Sutherland at 333 Maple Street.
Both elopement incidents involved the same resident leaving without proper assistive devices - a walker or wheelchair the person required for safe mobility. The resident's ability to exit undetected twice within three days, including once in the middle of the night, raised questions about facility supervision protocols.
The Director of Nursing's acknowledgment that facility policy was not followed suggests systemic problems with incident reporting and regulatory notification requirements. Adult Protective Services and state regulators remained unaware of either incident until federal inspectors arrived four days later.
The care plan developed September 19th proved ineffective within 24 hours when the resident left again without signing out or notifying staff of their destination. The plan's requirement for staff to "safely assist the resident through the doors" was not implemented when the resident departed unaccompanied at 3:59 AM.
Documentation gaps extended beyond missing incident reports. The facility's incident tracking system showed no record of the September 18th elopement, despite the Director of Nursing confirming it met elopement criteria requiring formal documentation and investigation.
The resident was discovered by police sitting in the road, suggesting they had been outside for an extended period before being found. The 3:59 AM timing indicates the departure occurred during overnight hours when staffing levels are typically reduced.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adept Nursing & Rehab of Sutherland from 2025-09-24 including all violations, facility responses, and corrective action plans.
Additional Resources
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