Park Regency Care Center: Resident Escapes Facility - CA
The August 17 incident involved a wheelchair-bound resident who had been flagged four days earlier for attempting to enter other female residents' rooms. Despite this documented wandering behavior, nursing staff never completed a required elopement risk assessment that could have prevented the escape.
The resident left the facility around 9:30 a.m. while a certified nursing assistant was busy with other duties and didn't hear the door alarm, according to inspection records from the California Department of Public Health. A laundry worker heard the alarm but chose not to respond.
"She did not get up and checked the door because she was on her lunch break and assumed somebody else would check the door alarm," inspectors wrote about the laundry staff member's response.
Police found the resident at a church around 10 a.m., roughly 30 minutes after the escape began.
The incident exposed multiple system failures at the 120-bed facility. Medical records show the resident had been assessed on August 13 for a "change in condition" after attempting to enter female residents' rooms, a clear sign of wandering behavior. But the required elopement risk assessment was never completed.
"The licensed nurse should have done the elopement risk assessment for Resident 1 to prevent episode of elopement," the facility's registered nurse told inspectors during interviews conducted after the escape.
The facility's own policy, revised in December 2022, explicitly states that residents who exhibit wandering behavior must receive adequate supervision to prevent accidents. The policy warns that alarms are not a replacement for necessary supervision and that staff must respond to alarms in a timely manner.
When the certified nursing assistant reported she couldn't find the resident around 9:30 a.m., facility staff began searching every room before initiating the elopement protocol. The registered nurse who supervised the response acknowledged the resident "had a history of attempting to enter female rooms."
The escaped resident had severe cognitive impairment according to facility assessments. Medical records also documented a skin injury measuring 3 centimeters by 4 centimeters on the resident's left forearm, discovered during evaluation on August 17, the same day as the escape.
During interviews with state inspectors, the certified nursing assistant admitted she was busy and didn't hear the door alarm when the resident left. She told her supervisor she never saw the resident leaving the facility.
The Director of Nursing acknowledged the failures during inspection interviews, stating that licensed nurses should have initiated an elopement assessment to identify the resident as an escape risk. She also confirmed that facility staff should have responded immediately to the door alarm.
Park Regency's administrator was informed of the inspection findings and acknowledged the violations on August 27.
The facility's elopement policy requires staff vigilance in responding to alarms, but the August 17 incident revealed a breakdown in this system. The laundry worker's decision to ignore the alarm during lunch break, combined with the nursing assistant's failure to hear it, created the window for the resident's escape.
State inspectors found the facility failed to provide necessary care and services to prevent accident hazards. The violation carried a potential for minimal harm designation, though the resident's cognitive impairment and the 30-minute unsupervised period outside the facility could have resulted in serious injury.
The resident was discharged from Park Regency Care Center on August 24, one week after the escape incident.
Federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent incidents like elopement. Facilities must assess residents for wandering and escape risks, then implement appropriate interventions.
The inspection was conducted following a complaint about the facility. Park Regency Care Center has faced scrutiny before for safety violations, though the specific nature of previous citations was not detailed in the current inspection report.
The August incident highlights ongoing challenges nursing homes face in balancing resident freedom with safety requirements, particularly for residents with dementia and cognitive impairment who may not understand the dangers of leaving supervised care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Regency Care Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
PARK REGENCY CARE CENTER in LA HABRA, CA was cited for violations during a health inspection on August 27, 2025.
The August 17 incident involved a wheelchair-bound resident who had been flagged four days earlier for attempting to enter other female residents' rooms.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.