A 97 year-old nursing home resident was injured when she fell from her bed to the floor after a nurse had turned her back to the resident. The resident was rushed to the hospital with a broken spine, but sadly, she died four days later.

The ensuing investigation found that, had a bed rail been in place, the accidental fall could have been prevented.

This is not the first time that Gramercy Court has been in the eye of the California Department of Public Health. In 2008, the facility was assessed a Class AA citation and fined after a resident died after facility staff failed to keep her hydrated.