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Santa Fe Heights: Fall Plan Failures Leave Resident at Risk - CA
Each time, licensed nurses documented the fall but left the December 2024 care plan unchanged....
Latest reports, citations, and penalties from CMS data
Each time, licensed nurses documented the fall but left the December 2024 care plan unchanged....
The incident unfolded on July 30, 2025, around 3:30 p.m....
The patient told inspectors two days later: "There was no RT at all....
The November 16 incident at Valley View Care Center involved a resident with severe cognitive impairment who regularly calls out for help in Spanish....
Federal inspectors found the facility failed to follow doctor's orders for wound care treatments between July and August....
The family member didn't recognize the housekeeper and immediately contacted an acquaintance who worked at the facility to retrieve the resident....
The January incident at Evergreen Post Acute began when Staff 33, a nurse, found several bottles of methadone in Resident 3's medication lock box....
Resident 43 suffered the fracture on November 16 at 11:40 a.m....
Resident #2 required partial to moderate assistance for transfers and had fallen before arriving at the facility....
The medication errors occurred across multiple shifts in August and September....
The cook admitted the breakfast was substandard but said time constraints prevented proper preparation....
The visitor alerted facility staff, who redirected the resident back inside....
The violation affected oversight for many residents, according to the November inspection report....
One resident's PICC line became completely blocked during their 16-day stay, forcing emergency removal when they transferred to a hospital on July 27....
Federal inspectors documented the hand hygiene failures during an October 29 observation at Azalea Health Center by Harborview....
Federal inspectors found the violation during a September 29 visit....
The employee at Focused Care of Center admitted during questioning that she knew her actions constituted theft....
Federal inspectors found the resident on September 29 at 11 a.m., lying in bedding saturated with urine from her lower back to mid-thighs....
The resident had undergone knee replacement surgery and was taking blood thinners, putting them at risk for dangerous blood clots....
Federal inspectors cited Belmont Terrace for medication management failures affecting three residents during a November complaint investigation....