Resident 1 at Meadowbrook Post Acute was supposed to be checked every 30 minutes after her May 13, 2025 fall that sent her to the hospital with a head injury. But nursing staff never documented doing those checks, the facility's Director of Nursing admitted to federal inspectors in December.
The resident had fallen from her bed to the floor on May 13, developing what hospital records described as a "small left frontal scalp hematoma." Emergency room doctors recommended a follow-up CT scan in six hours. Her family declined.
Eight months later, she fell again.
On December 21, 2025, at 4:20 p.m., a nursing assistant noticed discoloration around the resident's eyes. The morning shift aide reported seeing the discoloration around 8:30 a.m. but apparently hadn't acted on it for eight hours. Staff ordered emergency X-rays of both eye sockets and neurological checks.
The next morning, the resident couldn't stay still long enough for the X-ray. Staff sent her to the hospital again.
The Director of Nursing told inspectors the facility considers any time a resident is found on the floor a fall. This resident had six falls without documented injury between October 2024 and March 2025. She had two additional falls that caused injuries requiring hospitalization.
"Resident 1 is known for thrashing herself back and forth in the bed, banging on the wall and bed rails, and being found underneath her roommate's bed," the Director of Nursing told inspectors.
Despite this known behavior, the facility repeatedly failed to implement the monitoring schedules outlined in the resident's care plans.
Her October and November 2024 care plans required staff to check and change her every two hours. The Director of Nursing admitted there was no documented evidence this happened.
After her March 2025 fall, her care plan called for "frequent monitoring." Following the May head injury, staff were supposed to check on her every 30 minutes.
"There was no documented evidence in Resident 1's medical record, including the CNA task report and the nursing progress notes, that Resident 1 was frequently monitored or monitored every 30 minutes," the Director of Nursing told inspectors.
The nursing director acknowledged the facility's failures were systemic. "Resident 1's falls were avoidable if nursing had been frequently monitoring Resident 1 as indicated in the care plan," she said.
She admitted the facility "did not follow its own policies and procedures for keeping Resident 1 safe."
The facility's own policy, revised in July 2017, requires the care team to "target interventions to reduce individuals risk related to hazards in the environment including adequate supervision." The policy specifically mandates "ensuring that interventions are implemented."
The inspection found the facility failed to follow this basic requirement.
Between the resident's first documented fall in October 2024 and her December 2025 eye injury, staff had multiple opportunities to prevent harm through proper monitoring. The pattern showed escalating risk that went unaddressed.
Her falls occurred on October 4 and 10, 2024; November 7, 2024; December 4, 2024; February 19, 2025; March 3, 2025; May 13, 2025; and December 21, 2025.
The May 13 fall resulted in a head injury serious enough that her family requested she be sent to the hospital for evaluation. Hospital records documented her "contusion/hematoma" from the "unwitnessed fall."
The December 21 incident showed the same pattern of delayed response that characterized her care. Morning staff noticed eye discoloration at 8:30 a.m. but didn't report it until the evening shift at 4:20 p.m. The doctor wasn't notified until 4:37 p.m.
When staff finally tried to get X-rays the next morning, the resident was too agitated to complete the procedure. She had to be transported to the hospital instead.
Federal inspectors determined the facility caused actual harm to few residents through its failure to prevent accidents and provide adequate supervision. The violation represents a fundamental breakdown in basic safety protocols that nursing homes are required to maintain.
The resident's repeated falls and injuries occurred despite clear warning signs about her behavior and specific care plan requirements designed to keep her safe. Staff documented her tendency to thrash in bed and move around unsupervised, but failed to act on that knowledge with appropriate monitoring.
The facility's Director of Nursing acknowledged to inspectors that proper supervision could have prevented the falls that sent this resident to the emergency room twice in eight months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowbrook Post Acute from 2025-12-30 including all violations, facility responses, and corrective action plans.