Resident 127 left the building on May 11, 2025, and wasn't returned until later that day. The facility placed the resident on round-the-clock supervision only after the incident occurred.
Nobody had completed an elopement risk assessment for Resident 127, despite the person displaying what staff described as "exit-seeking behavior."
The second incident involved Resident 133, whose wander guard device was discovered to be off on October 17, 2025. The resident had been walking around the facility without the required safety equipment for an unknown period.
Staff secured the wander guard back on Resident 133 the same day they noticed it was missing. But the resident's admission record wasn't placed in the elopement monitoring binder at the front desk until October 19 — two days later.
As a precaution, the facility placed Resident 133 on one-to-one supervision on October 20.
When inspectors interviewed the Social Services Director and Infection Preventionist on October 23, she said elopement risk assessments should be completed when residents are admitted, quarterly, and "as-needed." Asked what "as-needed" meant, she replied it was when an assessment was incorrect.
The Administrator told inspectors she expected staff to complete elopement risk assessments at admission, quarterly, and whenever residents showed exit-seeking behaviors.
Neither standard was followed for the two residents who left unattended.
Federal inspectors determined the violations posed immediate jeopardy to resident health and safety — the most serious level of harm in nursing home enforcement. The facility submitted a removal plan that state surveyors accepted on October 23 at 11:20 PM.
Resident 127 remained under constant supervision until discharge on May 20, 2025. A nurse practitioner evaluated the resident on May 12, the day after the elopement incident, and nursing staff found no new impairments.
The facility's corrective action plan acknowledged that all residents at risk of elopement could be affected by the deficient practice. Licensed nursing staff conducted new elopement assessments on all residents on October 23, with follow-up based on findings.
Any newly identified at-risk residents would be evaluated for wander guard devices by the Director of Nursing, according to the plan.
The inspection was conducted in response to a complaint. Federal regulations require nursing homes to assess residents for elopement risk and implement appropriate safety measures for those who might wander or attempt to leave without supervision.
Elopement incidents can result in serious injury or death, particularly for residents with dementia or other cognitive impairments who may become disoriented outside the facility.
The facility's own removal plan confirmed that Resident 133's admission record was missing from the front desk elopement binder, while other unit binders had been properly updated. This gap meant staff at the main monitoring station lacked critical information about a resident at risk of leaving unattended.
For Resident 127, the facility acknowledged the person was placed on one-to-one supervision only after the elopement occurred on May 11, rather than proactively based on observed exit-seeking behavior.
The timing of the corrective actions — with new assessments conducted the same day inspectors interviewed administrators — suggests the facility recognized the scope of the problem only when federal surveyors arrived.
State survey agency acceptance of the removal plan on October 23 ended the immediate jeopardy status, but the underlying violations remain part of the facility's enforcement record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Albemarle Health & Rehabilitation Center from 2025-10-25 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Albemarle Health & Rehabilitation Center
- Browse all VA nursing home inspections