Rosemead Healthcare: Care Plan Failures Lead to Falls - CA
The resident sustained redness to her cheek from a March 20 fall and facial discoloration, eye swelling, and hand injuries from an April 9 fall. Staff had failed to implement basic fall prevention measures outlined in her care plan since October 2023.
The 83-year-old woman lives with bullous pemphigoid, an autoimmune disease causing large fluid-filled blisters on her skin, along with dementia and complete paralysis of her right arm, leg and trunk following a stroke. She requires total assistance transferring from bed to wheelchair and needs moderate help eating.
Her medical assessment from March indicated severely impaired cognitive skills and noted she lacked capacity to understand and make major decisions, though she could still make choices about daily activities like bathing and dressing.
Staff created a fall prevention care plan on October 16, 2023, specifically requiring them to keep personal items within the resident's reach and complete quarterly fall risk assessments. Inspectors found no evidence staff followed either requirement.
The facility's own fall management policy requires quarterly assessments for all residents with fall history. Staff failed to conduct these evaluations despite the resident's documented fall risk.
Beyond fall prevention failures, inspectors discovered staff routinely ignored the resident's expressed preference about where to eat meals. Family members met with the facility's interdisciplinary team on January 20, requesting their loved one be allowed to eat in the dining room rather than isolated in her bedroom.
A certified nursing assistant told inspectors on April 25 that meal location depended on "the resident's mood" and varied based on which aide was assigned each day. The aide said the resident ate in the dining room on April 21 but ate in her room on April 25.
"The assigned CNA would take Resident 1 to the dining room to have meals upon the family's request during visitation," the aide explained, suggesting staff only honored the preference when family members were present to advocate.
The facility's MDS nurse acknowledged during interviews that no care plan existed addressing the resident's dining preferences, despite the documented family meeting. The Director of Nursing confirmed staff discussed meal location preferences with family members but failed to create interventions respecting the resident's right to choose where she ate.
"Resident 1's rights and autonomy should be respected to improve quality of life," the Director of Nursing told inspectors, acknowledging the oversight.
The facility's own resident rights policy, dated October 2023, states residents may "choose activities, schedules, and health care that are consistent with their interests" including "sleeping, eating, exercise, and bathing schedules." Staff are required to "inform and regularly remind residents of the right to self-determination and participation in preferred activities."
A separate quality of life policy mandates that "residents are assisted in attending the activities of their choice."
The resident was initially admitted to Rosemead Healthcare Center in November 2021 and readmitted in February 2025. Her current condition requires total dependence on staff for bed-to-chair transfers and positioning, with wheelchair use for facility transportation.
Inspectors observed the resident on April 25 lying in bed with the head elevated to 90 degrees while a nursing assistant sat at eye level helping her eat lunch in her room, despite the family's documented request for dining room meals.
The inspection report indicates these care plan failures had "potential to result in a decline in the resident's mental, physical, and emotional well-being." Federal regulations require nursing homes to develop and implement complete care plans meeting all resident needs with measurable actions and timetables.
Staff violations affected both the resident's safety through ignored fall prevention protocols and her autonomy through disregarded dining preferences. The combination of physical injuries from preventable falls and social isolation from bedroom-confined meals represents the human cost when facilities fail to honor their most basic care planning responsibilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rosemead Healthcare Center from 2025-05-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ROSEMEAD HEALTHCARE CENTER in EL MONTE, CA was cited for violations during a health inspection on May 1, 2025.
The resident sustained redness to her cheek from a March 20 fall and facial discoloration, eye swelling, and hand injuries from an April 9 fall.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.