Resident #2 first disappeared on March 23 at 5:45 PM when staff discovered an empty bed during routine checks. The facility searched the room, activated a Code Orange emergency protocol, and called 911. Police responded to gather information while the facility waited for word on the missing resident's whereabouts.
The hospital emergency department called shortly after to report they had the resident.
The facility's investigation summary from that day documented specific new safety measures: Resident #2 would receive monitoring every 30 minutes for three days and one-to-one supervision at night. But staff never added these interventions to the resident's care plan.
Three weeks later, on April 14, Resident #2 escaped again. Police found the resident wandering on a nearby street and brought them to the emergency room for evaluation.
The resident had been admitted with adjustment disorder, dementia with mood disturbance and agitation, and Parkinson's disease. A January assessment documented severely impaired cognition and wandering behaviors occurring one to three days during the assessment period.
Registered Nurse #1 acknowledged the failure during a September interview with inspectors. "Resident #2's care plan should have been updated to reflect the new interventions indicated after the elopement," the nurse said. Care plans are implemented and revised by registered nurses, and "the staff member responsible for the investigation should have updated the care plan to ensure the interventions were reflected."
The Director of Nursing confirmed that whoever completes an incident report or investigative summary bears responsibility for revising the care plan to reflect new interventions. "Resident #2's care plan should have been updated to certify and reflect the intervention of one-to-one supervision following the elopement," the director said.
The oversight had operational consequences beyond the second escape. Registered Nurse #1 explained that certified nurse aide tasks generate directly from the care plan. Without revisions, staff wouldn't receive updated directives to implement required interventions.
The facility's own policy, revised in June, states that assessments are ongoing and care plans must be revised as information about residents' conditions change. Care plan interventions should be designed after careful consideration of the relationship between residents' problem areas and their causes.
Federal inspectors found the facility violated requirements to develop complete care plans within seven days of comprehensive assessments and ensure they're prepared, reviewed, and revised by health professionals.
The investigation revealed a systematic breakdown in the facility's safety protocols. Staff identified the elopement risk, developed appropriate interventions, but failed to incorporate them into the formal care plan that guides daily care decisions.
Documentation showed the required interventions were never implemented between the March and April incidents. The 30-minute monitoring checks and nighttime one-to-one supervision that investigators determined necessary after the first escape never occurred.
Hudson Hill Center operates on Ashburton Avenue in Yonkers. The facility houses residents with complex medical and cognitive conditions requiring specialized care and supervision.
The second elopement resulted in police involvement and emergency room evaluation, exposing the resident to potential harm from wandering unsupervised on city streets. The resident's dementia and severely impaired cognition made independent navigation dangerous.
Federal regulations require nursing homes to maintain comprehensive care plans that address all identified risks and needs. When facilities fail to update these plans after incidents, residents remain vulnerable to repeated safety failures.
The inspection occurred in November as part of an abbreviated survey following complaints about the facility's care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hudson Hill Center For Rehabilitation & Nursing from 2025-11-26 including all violations, facility responses, and corrective action plans.