Coventry Court Health Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the patio outside of the resident's room. The note further showed Resident 1 was noted lying on his left side with a cut in the forehead and multiple cuts and scrapes on the arms and legs. Review of Resident 1's SBAR Summary for Providers dated 8/28/25, showed the resident had a fall and the physician had ordered for the resident to be transferred to the acute care hospital. Review of Resident 1's IDT dated 8/29/25, showed Resident 1 had a fall on 8/28/25. The note showed prior to the incident, the resident had been wheeling self independently with constant supervision by nursing staff. The resident was last seen by the CNA and LVN by the nurse's station at around1440 hours. The note further showed the resident continued to wheel self and constant redirection had been offered to the resident, but had not been easily redirected.
On 9/25/25 at 1315 hours, an interview and concurrent medical review was conducted with RN 2. RN 2 stated Resident 1 was a wanderer. Resident 1 would wheel himself everywhere inside the facility and sometimes from room to room. When asked for how long Resident 1 was in the patio, RN 2 was not able to determine. RN 2 acknowledged the resident's whereabouts were not monitored. On 9/25/25 at 1430 hours,
an interview and concurrent medical review was conducted with the ADON/IP. The ADON/IP stated the resident would wheel self constantly and goes from room to room. The facility staff would always redirect Resident 1 and the resident would stop but would then continue to wheel himself aimlessly. When asked where did the CNA last saw Resident 1, the ADON/IP was unable to provide the information. The ADON/IP verified Resident 1 was alone and unsupervised in the patio when the fall incident happened. On 9/25/25 at 1615 hours, the Administrator and DON was made aware and acknowledged the above findings.
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COVENTRY COURT HEALTH CENTER in ANAHEIM, 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 ANAHEIM, 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 COVENTRY COURT HEALTH CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.