Guillermina Ruvalcaba suffered from various health conditions, including dementia and neuropathy. She had also undergone bilateral leg amputations.
After being hospitalized for diabetic ketoacidosis, she was admitted to Hacienda Heights Healthcare & Wellness Centre, an unlicensed skilled nursing facility.
Ruvalcaba’s admission assessment indicated that she was a fall risk due to her leg amputations. Approximately one month later, she wheeled herself without assistance to the facility’s day room. While still unsupervised, she fell out of her wheelchair and suffered a subarachnoid hemorrhage. An investigation into the incident led to a nursing director’s determination that her fall was unavoidable.