The incident at Princeton Manor Healthcare Center occurred between 11:30 p.m. and 2 a.m. on an unspecified date, according to federal inspection records. Resident 63, who had a documented history of elopement and was supposed to wear a wanderguard device, left the facility undetected during the night shift.
CNA 5, the nursing assistant assigned to the resident, told investigators he last saw Resident 63 at 11:30 p.m. lying on his bed with his cap on. The aide then went to his position in the hallway and became distracted by another resident who was walking around.
Around 1:30 a.m., LVN 8 asked the nursing assistant to escort the wandering resident back to his room. That task took him "maybe 20 minutes or less than 30 minutes," he told inspectors. When he returned around 2 a.m., he decided to check on his assigned residents.
Resident 63 was gone.
The nursing assistant immediately alerted LVN 8, and staff searched the bathroom and patio. Other nursing assistants joined the search, but the resident was nowhere to be found.
"CNA 5 acknowledged they were supposed to check the resident at least every two hours, and he should have checked Resident 63 at 1:30 a.m. and anything could have happened within the 30 minutes of not checking Resident 63," the inspection report states.
In reality, the gap was much longer. The nursing assistant had last seen the resident at 11:30 p.m. and didn't discover him missing until 2 a.m. That's two and a half hours without a safety check on a resident with known wandering behavior.
The facility's own care plan, initiated June 13, 2025, identified Resident 63 as having a "Risk for wandering/elopement." The plan called for use of a wanderguard device on his right wrist, with goals that "the resident will not leave facility unattended" and "the resident's safety will be maintained."
But the nursing assistant told investigators he didn't know if Resident 63 was wearing a wanderguard that night. No alarm sounded during the incident.
Resident 63 "used to get up and wander around from 2 a.m. to 4 a.m.," the nursing assistant said. Despite this known pattern, the facility's only interventions were "to just be alert and to check on Resident 63 at least every two hours."
That checking requirement never made it into the resident's written care plan, inspectors found. While the plan specified the wanderguard device, it "did not include checking on the resident every 2 hours by facility staff."
The nursing assistant said "only CNAs checked the residents, and the charge nurse sometimes reminded them about doing rounds." He acknowledged that "rounding every two hours was important to ensure the residents are okay, on their beds sleeping, and safe."
The facility had a policy requiring comprehensive person-centered care plans with "measurable objectives, and timeframes to meet a resident's medical, nursing, mental, and psychological needs." Another policy, revised in January 2023, required the interdisciplinary team to assess residents for elopement risk and develop individualized prevention plans.
But on the night Resident 63 disappeared, the systems failed. The wanderguard either wasn't functioning or wasn't being worn. The required safety checks weren't happening. And a resident with documented wandering behavior walked out undetected.
The nursing assistant told investigators this was Resident 63's first elopement at the facility, though he had a history of wandering elsewhere. Staff confirmed the side door was always locked and they didn't use it, but the resident still managed to leave.
The inspection report doesn't indicate whether Resident 63 was found or what happened to him after he left the building. It simply documents the 2.5-hour gap when nobody was watching a man known to wander, and the moment staff realized he was gone.
Federal investigators classified the violation as causing "actual harm" to residents, affecting "few" people at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Princeton Manor Healthcare Center, LLC from 2025-10-20 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Princeton Manor Healthcare Center, LLC
- Browse all CA nursing home inspections