Villa Rancho Bernardo Care Center
15720 Bernardo Center Drive, San Diego, CA 92127
Citation Number: 080006919
Citation Date: 02/03/2010
Violation Date: 2/25/2010
Class: AA
Penalty: $ 100,000

On 11/9/09, a resident who suffered from dementia died two days after falling down a concrete stairwell outside the facility and sustaining fatal head injuries. On the day of the fall, the resident exited an alarmed emergency door onto a stairwell landing while restrained in a wheelchair. The alarm sounded and the resident opened a second metal door and then fell down 20 concrete steps while still secured in his wheelchair. According to the autopsy report, the resident's cause of death was "complications following blunt force trauma of the head and torso." The facility failed to supervise the resident despite a history of wandering and exit seeking behaviors (the resident had attempted to exit the same door earlier the same day), and despite the resident's care plan calling for staff to keep the resident in an observed area. The facility was cited because these failures led to the resident's death.