The January 5th incident marked at least the third time the resident had left the facility without authorization since his admission in February 2023. Federal inspectors found no documentation of any elopement in the resident's medical record.
Administrator V1 told inspectors that an unidentified certified nursing assistant came to the front office asking if anyone had seen the resident, known in the report as R5. Staff began searching bathrooms and resident rooms throughout the building.
When they realized R5 was not inside the facility, they expanded the search to the surrounding area. The administrator drove two blocks east and saw emergency medical service lights at a coffee shop, where she found the missing resident.
"A concerned citizen had called 911 after seeing R5 walking with his walker," the administrator told inspectors during interviews conducted January 26th.
The resident had been seen walking in the hallway with his walker between approximately 3:50 PM and 4:15 PM that day, according to certified nursing assistant V6. After helping another aide, she was informed that staff could not locate R5.
V6 joined the search effort, driving with the activity director to locate the resident. They found him at the coffee shop where paramedics were already present.
Director of Nursing V2 said staff made her aware at 12:05 PM on January 26th that they were looking for R5 and could not find him. She immediately started searching back hallways and other resident rooms before learning the facility had received a call that R5 was found.
"She does not know why there is no documentation in R5's chart regarding the elopement and that it should have been documented in R5's electronic medical record," inspectors wrote. "V2 further stated she assumed the documentation was there."
The administrator was similarly unaware that the January 5th incident had never been recorded in the resident's chart.
This was not R5's first unauthorized departure. Shortly after his admission to the facility in February 2023, R5 had eloped because "R5 wanted to go to a parade, and nobody would take him," according to V3's statement to inspectors.
During that earlier incident, R5 was found walking on a busy street and brought back to the facility.
The administrator confirmed R5 had previously eloped in September 2023 and was found walking on a street. Again, no documentation of this incident appeared in his medical record.
Certified nursing assistant V8 told inspectors that R5 "got out of the facility, and nobody knew he had left." V8 stated that R5 has gotten out before, though she was not present during prior incidents.
V8 noted that R5's mobility varies depending on the day - he can ambulate with a walker or use a wheelchair.
The facility had not provided R5 with a wander guard device prior to January 5th. The administrator explained that R5 refused to wear the device, but this refusal was never documented in his medical record.
Federal inspectors classified the violations as immediate jeopardy to resident health or safety, the most serious level of harm in nursing home regulations. The facility is disputing the citation.
The nursing home submitted its first abatement plan on January 27th, but the regional office advised the facility to make revisions before it would be accepted. A second revised plan submitted January 28th also required additional changes.
The facility's final abatement plan was submitted January 29th and accepted by inspectors.
To remove the immediate jeopardy status, the facility implemented several corrective measures. All staff members present were trained on elopement policies and procedures on January 27th and 28th. Remaining staff members were scheduled for telephone training prior to their next shifts.
On January 28th, the administrator and director of nurses conducted an audit of medical charts to ensure proper interventions were in place and that all incidents were documented with actions taken.
All nurses received additional training on incident documentation and completion procedures from the Director of Nursing on January 28th.
The facility completed updated wandering and elopement assessments for all residents on January 27th, conducted by the Director of Nursing and Assistant Director of Nursing. Care plans were reviewed for accuracy by the Director of Nursing the following day.
The case highlights ongoing challenges nursing homes face in preventing elopements among residents with dementia and cognitive impairments. Residents who wander or attempt to leave facilities face significant safety risks, particularly when walking on busy streets or in unfamiliar areas.
The lack of documentation across multiple incidents suggests systemic problems with the facility's record-keeping and incident reporting procedures. Federal regulations require nursing homes to document all significant incidents affecting resident safety and wellbeing.
The repeated elopements also raise questions about the adequacy of the facility's supervision and monitoring systems for residents at risk of wandering.
R5's case demonstrates how residents with dementia may have specific triggers for attempting to leave, such as wanting to attend community events like parades. The facility's inability to address these underlying needs while maintaining safety protocols contributed to the recurring incidents.
The involvement of emergency medical services and concerned citizens in locating the resident underscores the community impact when nursing home safety systems fail.
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.