Studebaker Healthcare Center: Fall Care Plan Failures - CA
The resident, identified in inspection records only as Resident 2, was readmitted to Studebaker Healthcare Center with baseline confusion. That confusion was documented. It was known. And according to the Director of Nursing, it should have been addressed immediately upon his return to the facility. It wasn't.
He fell on February 11, 2026. He fell again on February 12.
On April 27, 2026, inspectors from the Centers for Medicare and Medicaid Services visited Studebaker Healthcare Center on a complaint inspection and reviewed what had happened during those two days and the weeks that followed. What they found was a care plan with no interventions addressing confusion, no physician orders targeting the problem, and no documentation in the resident's chart that anyone had treated his cognitive state as a fall risk at all.
The Director of Nursing confirmed it directly. There was no documentation in the chart, in the care plans, or in physician orders addressing Resident 2's confusion when he was admitted, she told inspectors. His baseline confusion on readmission should have been addressed right away to prevent his falls. It wasn't addressed before the first fall. It wasn't addressed before the second.
After the second fall, the facility's interdisciplinary team met on February 13 and discussed putting a tab alarm on the resident and placing bilateral floor mattresses beside his bed, both standard measures for a fall-risk patient with confusion. The Director of Nursing told inspectors that the team's failure to act on those decisions immediately was an oversight. The interventions weren't ordered until February 16, three days after the meeting. They were never added to the post-fall care plans at all.
That gap matters. A tab alarm alerts staff when a resident begins to move unsupervised. Floor mattresses cushion a fall if one happens anyway. For a confused resident who had already fallen twice, those were the tools his care team had identified as necessary. For three days after identifying them, nobody ordered them. For the entire period inspectors reviewed, nobody wrote them into the plan meant to guide his care.
The facility's own fall risk policy, dated February 24, 2026, stated that the interdisciplinary team would identify and implement appropriate interventions to reduce fall risk and that care plans would be updated to address new risk factors. The care planning policy, dated October 2023, required comprehensive, person-centered plans covering each resident's medical, nursing, mental, and psychosocial needs, with measurable objectives and timetables.
Resident 2's care plan had none of that. Not after the first fall. Not after the second.
CMS rated the violation as causing minimal harm or the potential for actual harm, affecting a small number of residents. That classification reflects the regulatory framework inspectors work within. It doesn't change what the Director of Nursing said out loud to inspectors on April 27: that a man came back to her facility confused, that his confusion was the reason he fell, and that her facility failed to write down a single thing about it until after he had already hit the floor twice.
The second fall did not have to happen. The Director of Nursing said so herself.
What happened to Resident 2 after February 12 is not detailed in the inspection report. Whether the floor mattresses, finally ordered on February 16, were ever put in place before he fell again, or before he left, the record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Studebaker Healthcare Center from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
STUDEBAKER HEALTHCARE CENTER in NORWALK, CA was cited for violations during a health inspection on April 27, 2026.
The resident, identified in inspection records only as Resident 2, was readmitted to Studebaker Healthcare Center with baseline confusion.
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.