Glenwood Gardens SNF
350 CALLOWAY DRIVE, BUILDING C, BAKERSFIELD, CA 93312
Citation Number: 120005216
Citation Date: 7/17/2008
Violation Date: 12/16/2006
Class: AA
Penalty: $ 100000.0

On 12/16/06, an 84 year old resident who suffered from dementia choked and subsequently died after swallowing a ketchup packet. He had a well-known history of attempting to eat non-edible items, and his care plan called for supervision to maintain his safety. Yet the facility did not detect him ingesting the ketchup packet, nor did it seek emergency medical attention when his health condition rapidly deteriorated on 12/16/08. Despite life threatening symptoms, he remained in the facility for over 12 hours until he died. Following his death, the coroner reported that a mortuary embalmer discovered the ketchup packet wedged in the back of his throat.