Rinaldi Convalescent Hospital: Fall Care Plan Failures - CA
Inspectors cited Rinaldi Convalescent Hospital, a nursing facility at 16553 Rinaldi Street, following a March 29, 2026 survey that found staff had failed to revise a resident's fall care plan after a documented fall, leaving a physician-ordered intervention off the books entirely.
The resident, identified in inspection records as Resident 12, had two fall-related care plans in place before the January incident. One, addressing fall and injury risks related to limited mobility, had been initiated on December 3, 2025. A second, a Safety and Fall Prevention care plan, was initiated December 19, 2025, and had most recently been revised on February 12, 2026. Neither was updated to reflect the landing pad order following the fall.
After Resident 12 fell on January 29, the facility's interdisciplinary team met and recommended placing landing pads at the bedside. The resident's physician agreed and ordered the pads placed on both sides of the bed that same day. The assistant director of nursing, interviewed by inspectors, confirmed the order was placed. She also confirmed the care plans were not updated to include it.
The December 3 care plan, the one specifically tracking fall and injury risk, was not reviewed or revised at all after the fall. The February 12 revision to the Safety and Fall Prevention plan came and went without any mention of landing pads.
The assistant director of nursing told inspectors that licensed staff are required to review and update all fall care plans following a resident fall to make sure new interventions are captured. She acknowledged that did not happen. She said the failure had the potential to result in inadequate care and an increased risk of injury to the resident.
The director of nursing, interviewed the same afternoon, said the same. Reviewing and revising care plans after a fall, she explained, is how staff assess whether current interventions are working and ensure that everything relevant to a resident's care is actually written down and followed. Skipping that step after a fall, she said, could result in inadequate care and a higher risk of the resident falling again.
The gap matters because care plans are not just paperwork. They are the document nursing staff refer to when deciding what precautions to take with a given resident. An intervention that exists only as a physician's order, without being incorporated into the care plan, can be missed during routine care. Landing pads are a low-tech but direct safeguard, placed on the floor beside the bed to reduce injury if a resident falls out during the night or attempts to get up unassisted.
Resident 12's situation was not a case where the facility failed to identify the problem. The interdisciplinary team met. They discussed it. They recommended the pads. The doctor ordered them. The system produced the right answer and then failed to record it in the place where it would actually govern the resident's day-to-day care.
By the time inspectors arrived on March 29, nearly two months had passed since the fall. The care plan still did not list landing pads as an intervention.
The inspection classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The facility's own policy, last reviewed on January 29, 2026, the same date as the fall, states that care plans are revised when a resident's condition changes significantly and that assessments are ongoing.
January 29 was the date of the fall. It was also the date the doctor signed the landing pad order. It was also, according to the facility's own records, the date the care plan policy was last reviewed.
The care plan was not updated anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rinaldi Convalescent Hospital from 2026-03-29 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 18, 2026 · Our methodology
RINALDI CONVALESCENT HOSPITAL in GRANADA HILLS, CA was cited for violations during a health inspection on March 29, 2026.
The resident, identified in inspection records as Resident 12, had two fall-related care plans in place before the January incident.
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.