Woodruff Convalescent Center – Class AA Citation & Maximum Fine After Patient Fell 5 Times, Dies

The California Department of Public Health, or CDPH, recently announced that the agency had slapped a Class AA citation and a $100,000 fine on Woodruff Convalescent Center after–as the Department’s press release put it–“deficiencies” with a patient’s care “were determined to have been a direct proximate cause of death”.

The penalties are the most severe the state can levy in a nursing home death.

CDPH investigators first became aware of the patient’s plight back in January when they made an unannounced visit to the nursing home. The visit, according to investigators, was prompted by a complaint alleging that a patient had suffered “several falls” during his stay in the facility.

The patient, as it turned out, was an 82-year-old blind man with dementia. The man, who was taking blood thinners, had reportedly fallen 5 times since being admitted to the facility. After his fifth fall, which happened in late November of 2016, the man died.

In the official Statement of Deficiencies and Plan of Correction, investigators made a number of allegations against Woodruff Convalescent Center. Those allegations include:

  • Failure to adequately supervise his day-to-day movements
  • Failure to adequately supervise his bathroom visits
  • Failure to complete or conduct required neurological checks after each fall episode
  • Failure to assess his use of a his wheelchair’s physical restraint system
  • Failure to monitor him while he “escaped” his wheelchair restraints
  • Failure to review and revise his fall prevention measures
  • Failure to obtain a doctor-ordered psychiatric visit to treat his suspected anxiety
  • Failure to notify is doctor of an abnormal blood clotting result

The patient’s fifth fall occurred in the very early morning of November 02, 2017. He was found on the floor, out of his wheelchair, and bleeding from his forehead. The staff called 911 and he was taken to a hospital. He died a month later from what was determined to be an acute and chronic subdural hemorrhage and fall, blamed on the fall he suffered at Woodruff Convalescent Center.

The patient’s name has not been made public.


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