Valley Gardens Health Care & Rehabilitation Center
1517 East Knickerbocker Drive, Stockton, CA 95210
Citation Number: 030006639
Citation Date: 10/21/2009
Violation Date: 11/21/2007
Class: AA
Penalty: $ 90,000

A 92 year old resident died on 6/14/07, less than 30 hours after suffering a fall at the facility. The resident, who was on a diuretic medication that made him urinate frequently, got out of bed and fell in the bathroom. An aide found him on the bathroom floor, contacted a nurse, and they put him back to bed without further action because the nurse said he did not have any injuries. In fact, the resident had suffered a severe subdural hematoma (bleeding of the brain) and was hospitalized in a comatose condition a few hours after he fell. The facility was cited because it failed to provide adequate supervision to prevent falls and did not take appropriate action to adjust and implement his care plan after he suffered another fall about 3 weeks earlier. These failures led to the resident's death.