"The facility treated the falls but did not look into the possible causes of the falls and did not know if Resident 1 had increased impulsive behavior leading to further falls," the administrator told federal inspectors during a September complaint investigation.
The admission came after inspectors discovered the facility had failed to follow its own fall prevention protocols for a resident who had been falling repeatedly while attempting to get out of bed unassisted.
Resident 1's care plans from May and August showed a pattern of "altered behavior patterns related to attempting to get out of bed unassisted." The plans noted the resident's tendency toward "movement to floor mat" but failed to dig deeper into why these behaviors were occurring.
When inspectors asked whether the facility had assessed causative factors as indicated in the care plans, the administrator said they "were not aware of causative factors." The administrator added that if causative factors were listed as an intervention in the care plans, "it should have been followed."
The facility's own policy, titled "Falls and Fall Risk, Managing," required staff to "implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident with a history of falls." The policy specifically called for identifying and addressing individual risk factors, not just applying standard interventions across the board.
But the administrator told inspectors that Resident 1's fall prevention care plan contained only "standard fall prevention interventions used for any resident that was at high risk for falls."
The facility's physical therapy director revealed another troubling pattern during the inspection. Despite working with Resident 1 from July through September 2025, the resident's physical therapy goals had remained completely unchanged. "Resident 1's physical therapy goals had not changed from 7/2025 to 9/2025," the therapy director told inspectors, adding that they had worked on "bed mobility and strengthening exercises the entire time."
The therapy director acknowledged there were "slight differences in emphasis depending on Resident 1's progress but the big picture remained constant." This static approach suggested the facility was not adapting its interventions based on the resident's actual response or changing needs.
The facility's policy required staff to "observe each resident's response to interventions intended to reduce falling or the risks of falling." When asked about monitoring effectiveness, the administrator claimed the current interventions were working because "Resident 1 would have otherwise fallen more often."
However, the administrator then contradicted this assessment, admitting "the facility did not have documented evidence to indicate fall prevention interventions were evaluated for effectiveness and the facility did not do the depth of evaluation that was perhaps needed."
The facility had assigned a sitter to stay with Resident 1, which the administrator described as preserving the resident's dignity while avoiding restraints. The administrator emphasized they had "done everything possible without resorting to restraints" and that the fall prevention interventions listed in the care plans were "standard interventions."
But the facility's own "Falling Star Program" policy included specific recommendations for "evaluation for appropriate useful interventions for fall reduction," suggesting the facility knew it should be doing more individualized assessment and intervention.
The gap between policy and practice became clear during the inspection. While the facility had detailed written procedures calling for resident-centered approaches and ongoing evaluation of intervention effectiveness, staff had instead relied on generic fall prevention measures without investigating the underlying causes of this particular resident's repeated attempts to leave bed unsupervised.
The administrator's admission that they didn't know whether the resident had "increased impulsive behavior leading to further falls" highlighted the facility's failure to understand the individual factors driving the dangerous behavior. Without identifying these root causes, the facility was essentially treating symptoms rather than addressing the problem.
Federal inspectors found the facility's approach violated requirements for comprehensive fall prevention programs. The citation noted "actual harm" to residents, indicating the deficient practices had already resulted in negative consequences.
The inspection revealed a facility going through the motions of fall prevention without the individualized assessment and ongoing evaluation that effective programs require. Despite months of physical therapy focused on the same goals and care plans noting problematic behaviors, no one had stepped back to ask the fundamental question: Why does this resident keep trying to get out of bed alone?
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa Bonita Convalescent Hospital from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Casa Bonita Convalescent Hospital
- Browse all CA nursing home inspections