BAKERSFIELD, Calif. (KGET) — A wrongful death lawsuit filed against Kingston Healthcare Center, which closed earlier this year after losing its license and agreement with Medicare and Medicaid, is now in arbitration, according to court records.

The suit, filed two years ago by Bakersfield law firm Chain Cohn Clark, accuses the facility of failing to properly care for 79-year-old Javier Chavolla Villasenor, who stayed at Kingston from July 24 to Aug. 31, 2019. The firm is representing his widow and children.

Chavolla (as he’s referred to in the lawsuit) had a number of factors putting him at high risk for falls, including dementia, weakness, unsteady balance and a history of falling. He was dependent on others for moving and eating and a resident care plan created by Kingston identified him as an at-risk resident.

Despite his risk assessment, Kingston’s “care plan was inadequate and the interventions mandated were never appropriately implemented,” the suit says. Staff either responded slowly or not at all when Chavolla and other patients activated their call lights, and nursing staff weren’t adequately trained to care for him.

“As a result of these failures to provide necessary care, during Mr. Chavolla’s first five weeks at Kingston, he suffered from one known fall which caused severe injury and ultimately led to his death,” according to the suit.

The fall happened Aug. 31, 2019, when he requested a nurse to help him to the bathroom.

“The nurse failed to take Mr. Chavolla to the restroom, causing him to self-ambulate, which ultimately led to him falling and hitting his head and back,” the suit says. About 45 minutes passed from the time a nurse responded to Chavolla’s roommate’s calls for help to when the facility called an ambulance, it says.

Chavolla was taken to San Joaquin Community Hospital, where he died Sept. 9, 2019. His death certificated identified causes of death including bleeding inside the skull and loss of blood flow to part of the brain.

Kingston achieved notoriety when the COVID-19 pandemic began, with dozens of residents testing positive, many dying. And the federal medicare.gov website in 2020 said Kingston had a poor record of patient care, receiving 39 citations in three years. The website said the state average of citations was 13 and the national average was 8.