Casa de las Campanas: Fall Care Plan Failures - CA
The August 1 incident involved a resident admitted with a broken right thigh bone and generalized muscle weakness. Staff had already classified him as high risk for falling in a June evaluation.
Licensed Nurse 1, who supervised the unit that morning, found the resident on the floor next to his bed around 10:19 a.m. "Found resident on the floor, left side of the bed, head slightly under the bed," according to progress notes. The resident explained he wanted to reach his wheelchair to go to the bathroom and hit his head on the side of the bed.
The nurse's assessment revealed a skin tear on the back of his head that was bleeding slightly. The resident reported pain at level 7 on his right hip. Staff transported him to the hospital via 911 per physician's order.
His call light was not activated when the nurse entered the room.
The resident returned to the facility the same day, but no new interventions were documented in his record. During the August 22 inspection, Licensed Nurse 1 described what should have happened: "We reiterated that he needs to press the call light. If he's in bed it needs to be in the lowest position, and fall mats."
She could not remember if these interventions were actually implemented when the resident returned.
The Interim Director of Nursing confirmed the failure during inspection interviews. "There were no new interventions documented in Resident 1's record when he returned from the hospital," she told inspectors. "I would have done something like move him closer to the nurses station."
She acknowledged the care plan should have been updated immediately. "Resident 1's care plan should have been accelerated to reflect the fall," she said. "It was important to prevent future falls, to try to avoid injury and cause harm to the resident."
The facility's own policy required exactly what didn't happen. According to the Falls Clinical Protocol revised in March 2018, staff and physicians must "continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable."
The policy further mandates that "based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling."
When underlying causes cannot be identified or corrected, staff must "try various relevant interventions" and "monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling."
None of this happened after the August 1 fall.
The resident's vulnerability was well-documented. His admission record showed diagnoses including the fractured right femur and generalized muscle weakness. The June 5 fall evaluation had already flagged him as high risk.
Federal inspectors found the failure created potential for the resident to experience additional falls and injuries. The facility was required to develop a complete care plan within seven days of comprehensive assessment, prepared and reviewed by a team of health professionals.
Instead, a resident with documented fall risk, recent injury, and demonstrated difficulty safely accessing basic needs like bathroom facilities was returned to the same conditions that led to his hospitalization.
The August incident highlighted the gap between policy and practice at Casa de las Campanas. While facility protocols outlined comprehensive fall prevention measures, staff failed to implement them for a vulnerable resident who had just demonstrated the consequences of inadequate precautions.
The resident's attempt to independently reach his wheelchair revealed both his determination to maintain some autonomy and the facility's failure to provide safe alternatives. His explanation that he simply wanted to use the bathroom underscored how basic human needs became dangerous when proper safeguards were absent.
The bleeding head wound and level 7 hip pain represented more than just physical injury. They marked a missed opportunity to prevent future harm through the systematic care planning process the facility had committed to follow.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa De Las Campanas from 2025-08-22 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
CASA DE LAS CAMPANAS in SAN DIEGO, CA was cited for violations during a health inspection on August 22, 2025.
The August 1 incident involved a resident admitted with a broken right thigh bone and generalized muscle weakness.
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.