Yonkers Gardens Center For Nursing And Rehab

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wired and alarmed. The Certified Nurse Aide accountability documents wander guard every shift. The Out

on Pass process is usually determined by the team, there is a physician order. The supervisor or social worker will explain the process of Out on Pass to the family. During an interview on 09/16/2025 at 11:47 AM, Resident #3's family stated that in May of 2024 around 12 or 1 AM Resident #3 walked out, and nobody found them until 14 hours later, on a corner near the facility. From what the family was told by the facility, the resident was found sitting on the floor, leaning up against a wall, sleeping. The facility told resident's family that they didn't realize their family was missing at first as the resident never showed signs of potential for elopement. Since the incident they have put a wrist band on Resident #3 so that going forward the facility is notified if resident tries to leave floor or facility. The family questioned why the facility didn't already have a wrist band on Resident # 3 since he has dementia. During an interview on 09/16/2025 at 11:56 AM, Resident #3's family stated they do not understand why the nursing home took so long to report the incident. They further stated they do not understand why someone with dementia would not have

a wander guard. Family claimed there was no one at the nurse's station or front desk keeping an eye on residents so it was too easy for Resident #3 to leave the facility. Resident #3's family mentioned several times how frustrated they were with the delay in the investigation and stated they are still very upset about Resident #3 missing. Family stated that Resident #3 never expressed intention to leave facility. Family stated that they put Resident #3 in a nursing home to get quality care and because family could no longer look after Resident #3. Family noted that when Resident # 3 di live with family, they never eloped or went missing. Family states that Resident # 3 now expresses a wish to leave this prison and that family is making plans to bring them back home. Family feels facility needs to pay more attention to their residents or find a new profession. During an interview on 09/16/2025 at 1:19 PM, Registered Nurse # 13 stated that Resident #3 was friendly, fully dressed and talking with other residents on the day of the incident. They stated Resident #3 never mentioned wanting to leave the place and that they never noticed Resident #3 going to

the elevator alone. They stated that at around 4:30 PM Resident #3 was laughing with fellow residents and that at around 6:00 PM Resident #3 was observed in the dining room. They stated that the Certified Nurse Aide # 3 realized resident was missing and informed them, who then reached out to the supervisor, who called the elopement Code Purple and called local police. Staff searched facility and then went out into the streets to search for Resident #3. Attempted to call Security Guard # 16 on 09/16/2025. Message left at 2:51 PM. Message left at 3:04 PM. No call back.During an interview on 09/16/2025 at 2:25 PM, Nursing Supervisor # 10 stated they do not have exact recollection of incident. Stated that the responsibility of a nursing supervisor is to act once staff informs them of a missing resident, then organizes a head count of all residents throughout the facility, instructs staff to go around the immediate area surrounding the nursing facility, contact the resident's physician, the local police, and Out on Pass/emergency contact. Nursing Supervisor #10 stated that it is the Director of Nursing's is responsible for reporting the incident to the NYS DOH. During an interview on 09/16/2025 at 3:12 PM, the facility Administrator stated that Resident #3 left

the facility without permission, and the facility investigation concluded that there was an elopement. There was camera footage showing the resident leaving the main entrance on 5/22/25 with three other people who were leaving the facility. Stated the security guard was in view of the front entrance. States that the double doors of main entrance were not locked at the time of incident, and a lock has since been added.

Stated education was done, security guard was replaced, and lock was added to the front door after incident. Security guard on date of incident was from the agency and he was replaced by another agency security guard. 10NYCR 483.25 (d)(1)(2)

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