Casa De Las Campanas
Inspection Findings
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to update the plan of care for one of three residents (Resident 1) reviewed for falls.This failure had the potential for Resident 1 to experience subsequent falls and/or injuries.On 8/22/25 Resident 1's facility's record was reviewed. The admission Record indicated Resident 1 was admitted on [DATE REDACTED] with diagnoses which included fracture of right femur (a broken thigh bone) and generalized muscle weakness. A review of the Fall Evaluation dated 6/5/25 indicated Resident 1 was at high risk for falling. During a review of Resident 1's Progress Notes, the Fall Note dated 8/1/25 at 10:19 A.M. indicated, .found resident on the floor, left side of the bed, head slightly under the bed. When asked, [Resident 1] stated he wanted to reach his wheelchair to go to the bathroom and hit his head on the side of
the bed. Assessment done, skin tear on the back of the head slightly bleeding, and pain with level of 7 on
the right hip. The Progress Note indicated Resident 1 was transported to the hospital via 911, per physician's order.On 8/22/25 at 9:50 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated she was the supervising nurse on duty when Resident 1 sustained a fall on 8/1/25. LN 1 stated she assessed Resident 1 while he was still on the floor. LN 1 stated Resident 1's call light was not activated when she entered his room. LN 1 stated resident was sent to the hospital immediately, and returned the same day. LN 1 stated the new interventions initiated by the facility to prevent Resident 1 from sustaining any additional falls include, .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. LN 1 stated she does not remember if the interventions were implemented when Resident 1 returned to the facility.On 8/22/25 at 10:23 A.M., a joint
interview and record review was conducted with the Interim Director of Nursing (IDON). The IDON stated there were no new interventions documented in Resident 1's record when he returned from the hospital.
The IDON stated, I would have done something like move him closer to the nurses station. The IDON stated Resident 1's care plan should have been accelerated to reflect the fall. The IDON stated it was important to prevent future falls, to try to avoid injury and cause harm to the resident.On 8/22/25 the facility's policy was reviewed. The facility's policy titled Falls- Clinical Protocol revised March 2018, the policy indicated, The staff and physician will 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.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.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
CASA DE LAS CAMPANAS in SAN DIEGO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN DIEGO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CASA DE LAS CAMPANAS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.