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A San Francisco skilled nursing facility has been cited and fined $100,000, the largest ever imposed in California, after the California Department of Health Services determined that the poor care of an 82-year-old resident with dementia led to her death. The nursing home resident who had a history of falling and wandering, was found unresponsive on the ground outside the nursing home facility. The state agency said that facility managers failed to review, evaluate, update and implement a care plan for the resident, and failed to control the resident’s history of wandering outside.

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