The resident, identified as R5 in the inspection report, had previously escaped the facility in September 2023 and was found walking on a busy street. He eloped again shortly after his February 2023 admission because he wanted to attend a parade and no one would take him.
On January 5th, an unidentified nursing assistant came to the front office asking if anyone had seen R5. Administrator V1 said staff began searching bathrooms and resident rooms throughout the facility.
When they realized R5 was not inside the building, they expanded the search to the perimeter. V1 drove two blocks east and saw emergency medical service lights at a local coffee shop.
She found R5 there.
A concerned citizen had called 911 after seeing the resident walking with his walker, according to V1's account to inspectors on January 26th.
The search lasted approximately 30 minutes. Certified nursing assistant V6 saw R5 walking in the hallway with his walker between 3:50 PM and 4:15 PM. After helping another aide, she was informed that staff could not locate R5.
V6 joined the search and drove with the activity director to look for him. They also found the EMS lights at the coffee shop where R5 had been located.
Nobody documented the elopement in R5's electronic medical record.
Director of Nursing V2 told inspectors on January 26th that she did not know why there was no documentation regarding the incident. "It should have been documented in R5's electronic medical record," V2 stated. She said she had assumed the documentation was there.
V1 told inspectors she was not aware the incident had not been documented in R5's chart.
The facility's failure to document the elopement violated federal nursing home regulations and created what inspectors classified as "immediate jeopardy to resident health or safety."
R5 did not have a wander guard prior to January 5th because he refused to wear it, according to V1. The administrator confirmed that this refusal was never documented either.
The resident can walk with a walker or use a wheelchair depending on the day, according to certified nursing assistant V8. V8 told inspectors that R5 "got out of the facility, and nobody knew he had left."
V8 said R5 had escaped before, though she was not present during those prior incidents.
The pattern of undocumented elopements raises questions about how many times R5 may have wandered away without staff knowledge. The inspection report confirms at least three separate incidents: the January 5th coffee shop discovery, the September 2023 street walking episode, and the parade-related escape shortly after his February 2023 admission.
Certified nursing assistant V7 was working during the January 5th incident but was not involved in the search because she was helping another resident. She told inspectors she was informed that R5 had gotten out of the facility.
The facility's response to the immediate jeopardy citation took multiple attempts. Inspectors initially rejected two abatement plans before accepting the final version on January 29th.
The approved corrective actions included mandatory staff training on elopement policies conducted on January 27th and 28th. All staff members present during those dates received in-service training. Remaining staff members were scheduled for telephone training from the administrator or designee prior to their next shifts.
On January 28th, the administrator and director of nursing audited R5's medical chart to ensure proper interventions were in place and that documentation of the event and all actions taken were recorded.
The director of nursing provided additional training to all nurses on January 28th regarding incident charting and completion procedures.
The facility also conducted updated wandering and elopement assessments for all residents on January 27th. The director of nursing and assistant director of nursing completed these assessments. Care plans were reviewed for accuracy by the director of nursing on January 28th.
Inspectors confirmed on January 29th through observation, interviews, and record review that the facility had implemented these corrective measures to address the immediate jeopardy.
The nursing home is disputing the citation, according to the inspection report.
Federal regulations require nursing homes to provide adequate supervision for residents with cognitive impairments who may be at risk of wandering. Facilities must assess each resident's elopement risk and implement appropriate interventions, including documentation of all incidents and refusals of safety equipment.
The case highlights the vulnerability of dementia patients in long-term care settings. R5's ability to leave the facility undetected on multiple occasions, combined with staff's failure to document these serious safety incidents, represents a systemic breakdown in resident protection protocols.
The involvement of emergency medical services and concerned citizens in locating a missing nursing home resident underscores the potential community safety implications when facilities fail to adequately supervise at-risk residents.
R5's refusal to wear a wander guard, while documented as the reason for not providing one, does not absolve the facility of responsibility for implementing alternative safety measures and documenting all elopement incidents as required by federal regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monmouth Rehab and Nursing from 2026-01-29 including all violations, facility responses, and corrective action plans.