Villa Rancho Bernardo Care Center
15720 Bernardo Center Drive San Diego, CA 92127
Citation Number: 080009783
Citation Date: 03/13/2013
Violation Date: 10/28/12
Class: AA
Penalty: $100,000

On 10/28/12, a 61 year old male resident with dementia choked to death after he was given uncut pancakes and sausage patties despite having orders for chopped food because of his aggressive and compulsive eating. The facility cook, food line checker, licensed nurse and a CNA all failed to catch the mistake despite handling the resident's food tray. The food line checker claimed that she was quite busy because she also answers the phones on Sundays while the licensed nurse said she was in a hurry too. No findings were made regarding the facility's sufficiency of staffing. The facility was cited for failing to follow the physician's orders for a chopped diet.