Holiday Manor Care Center
20554 Roscoe Blvd. Canoga Park CA, 91306
Citation Number: 920011776
Citation Date: 12/01/2015
Violation Date: 9/8/2014
Class: AA
Penalty: $100,000

On 9/8/14, a female resident fell in her room near her bed, sustaining a head injury. She was found moaning on the floor in the seated position. She later developed an intracranial hemorrhage (bleeding in the brain), and died on 9/17/14. The immediate cause of death was blunt force head trauma. The resident was considered high risk for falls/injuries due to her diagnoses of dementia, psychosis, anxiety, and depression. She was prescribed psychotropic medications due to psychosis. The nurse that found her on the floor stated that the resident routinely went to the bathroom by herself unassisted. Another CNA explained that the CNAs were to document the level of assistance provided and her mobility status, but the forms were incomplete. The facility failed to ensure the resident was monitored for unassisted transfers and walking, ensure the nursing staff was aware of her assistance requirements, implement and reevaluate the plan of care when needed, and implement the facility's policy and procedure on Falls, Risk for and Actual Fall.