Nobody at the nursing home noticed Resident #127 was missing until nearly two hours after the 8:55 PM escape on May 11, 2025. The family member who received the resident's phone call at 11:08 PM had to tell facility staff where to find their missing patient.
Licensed Practical Nurse #20, assigned to care for the resident, failed to implement the facility's missing person protocol called Code Orange. The administrator wasn't informed of the elopement until 10:48 PM, almost two hours after the resident had left the building.
Staff never called the resident's family to report them missing.
Local police and a facility staff member eventually brought the resident back from the baseball game. But the administrator's investigation into how a vulnerable resident walked out undetected consisted of a single interview with the nurse on duty.
"Possibly more interviews were needed and should have been conducted," Administrator told federal inspectors during an October 18 interview, according to the inspection report.
The facility's investigation file contained only LPN #20's statement. No other staff members who worked that evening were interviewed. No staff who participated in searching for the resident were questioned about what happened.
During a follow-up interview two days later, the administrator acknowledged the investigation fell short of her own expectations. She said she expected "a root cause analysis was determined so that the facility would know where the break down in the process was not followed."
The administrator told inspectors she expected interviews "with all the staff that worked and everyone who participated in the Code Orange."
Federal inspectors found the administrative failure affected one of four residents they reviewed for accidents during their October 25 complaint investigation.
Resident #127 had been identified by the facility as having exit-seeking behaviors, meaning staff knew they were prone to trying to leave. Despite this known risk, the resident managed to walk out of the building without anyone noticing for nearly two hours on a Saturday evening.
The facility's job description for the administrator, revised in April 2023, states the position is "directly responsible for the overall successful operations of the healthcare center" and must ensure "residents are consistently receiving care and services in line with the company's vision of Care Beyond Care."
The Director of Nursing job description, updated in May 2023, requires oversight of nursing services and compliance with federal, state and local regulations governing skilled nursing facilities.
But when a resident with known wandering tendencies disappeared for almost two hours, the facility's response violated its own protocols. The Code Orange missing person procedure wasn't properly implemented. The family wasn't notified their loved one had vanished.
The resident had to rescue themselves, using their cell phone to call for help from wherever they had wandered in Charlottesville that Saturday night.
The administrator initially told inspectors that LPN #20 had enacted Code Orange and defended the limited scope of the investigation. But under questioning, she admitted the facility should have conducted a more thorough review.
"She expected there should have been interviews with all the staff that worked and everyone who participated in the Code Orange," inspectors wrote in their report.
The deficiency represents what federal regulators classified as "minimal harm or potential for actual harm." But for Resident #127, the consequences of the facility's failures were immediate and frightening - alone at a baseball game on a cold night, having to call family for rescue because their nursing home didn't know they were gone.
The inspection report doesn't indicate whether the resident suffered any physical harm during their unsupervised hours away from the facility. It also doesn't reveal how the resident with exit-seeking behaviors managed to leave the building undetected, or what security measures were in place to prevent such escapes.
What's clear is that when the system failed, a vulnerable resident was left to fend for themselves in an unfamiliar location, cold and needing help that should have come from the facility responsible for their care and safety.
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
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