Rosemead Healthcare: Fall Response Team Failed - CA
Resident 2 at Rosemead Healthcare Center first fell on April 19, found on his bedroom floor after what he described as slipping out of his wheelchair while leaning forward. His doctor ordered neurological checks for 72 hours. His fall risk assessment scored him at 35, indicating moderate risk.
Three days later, he fell again.
On April 22 at 10:30 p.m., staff found Resident 2 lying on the floor in front of his wheelchair. He had a 2.5 by 2.5 centimeter bump on the left parietal area of his head — near the back and top, where the brain processes sensory input. He rated his pain as 3 out of 10.
"He stated he was sitting in his wheelchair and wanted to catch the urinal, but lost balance and was laying on the floor," nursing notes recorded. Staff gave him an ice pack and notified the doctor, who issued no new orders.
After the second fall, Resident 2's risk assessment jumped to 60 — high risk for falling. He received another 72 hours of neurological monitoring.
But the facility's interdisciplinary team never convened to analyze either incident.
During the August inspection, Director of Nursing admitted the facility had no documentation showing the required team meetings occurred. "The DON stated the facility does not have an IDT documentation note for Resident 2's falls that occurred on 4/19/25 and 4/22/25," inspectors wrote.
The director acknowledged the team "met as a group, but the DON could not find any IDT note in Resident 2's medical record indicating the falls were evaluated and discussed by the IDT."
The facility's own Fall Management Program policy, implemented in October 2023, requires the interdisciplinary team to meet within 72 hours of any fall. The team must document a summary of the event, conduct root cause analysis, make referrals as necessary, and plan interventions to prevent future falls.
Licensed Vocational Nurse 1 explained the facility's standard fall response during an interview with inspectors. When residents take blood-thinning medications or experience unwitnessed falls, they're automatically sent to the hospital unless they refuse. Fall skin assessments are completed immediately or the next day for nighttime incidents. Nurses complete change-of-condition forms and notify doctors and families.
But the interdisciplinary review — the step designed to prevent the next fall — didn't happen.
The director of nursing could only provide team meeting notes from March 31, shortly after Resident 2's admission, and June 26, for discharge planning. No notes existed for the critical period when he fell twice and his risk level escalated from moderate to high.
Resident 2 was taking multiple medications that required monitoring for side effects including sedation, drowsiness, and weight gain. His medication regimen included Escitalopram Oxalate, requiring monitoring for photosensitivity and weight gain, plus antipsychotic medications Haloperidol and Quetiapine Fumarate, which can cause sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, sweating, loss of appetite, and urinary retention.
The first fall was unwitnessed. The second occurred when Resident 2 tried to reach for his urinal while seated in his wheelchair — a specific action that could have informed targeted interventions.
"The DON stated the facility missed the opportunity to evaluate Resident 2's falls that occurred on 4/19/25 and 4/22/25 and update the care plan with interventions to mitigate or prevent future falls," the inspection report concluded.
Federal inspectors determined the violation caused minimal harm or potential for actual harm to few residents. But for Resident 2, whose fall risk doubled after his head injury, the missed opportunity meant continuing to navigate his daily activities without the benefit of a comprehensive safety review designed specifically to prevent his next fall.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rosemead Healthcare Center from 2025-08-13 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 August 13, 2025.
His doctor ordered neurological checks for 72 hours.
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.