* Park Central Nursing and Rehabilitation Center in Fremont, owned by the Regency Health Services chain, was cited in January after failing to notify a doctor or assess a patient's leg fracture for at least five days. The patient was transferred to a hospital with infection and died three days later.
* Also in January, an ombudsman in Petaluma found a patient at Pleasant Care Convalescent Home lying naked in a bed in a room with the light off. According to a citation report, the patient had become dehydrated and malnourished over a two-week span. She died the day after having been found by the ombudsman.
* Heart of Napa, owned by TLC of the Bay Area, was cited in January after a patient developed 26 bedsores because the staff had failed to even move him in bed.
* In June, an 86-year-old woman at Hillhaven's Pine Towers facility in San Francisco was found lying on the floor with her bed linen wound around her. The side rail of her bed was down. An inspector's report noted that the woman had been diagnosed with a variety of ills, including "trauma potential related to her history of seizures." The physician's orders called for both side rails on her bed to be up at all times. According to the report, the nurse's assistant in charge of this patient said that "she's not sure if she put the side rails up after [the patient] was changed." The patient died five hours later.