Meadowbrook Post Acute
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
note dated May 19, 2025, at 7:10 p.m., indicated .family at bedside and requested resident be sent to (name of hospital) for evaluation of s/p (status post) fall (May 13, 2025), MD notified and order to send to hospital.resident present with contusion/hematoma s/p unwitnessed fall.resident transferred.The (named hospital) emergency room note dated May 19, 2025, indicated .fall on May 13 from the bed to the floor.CT head.small left frontal scalp hematoma.recommend follow up CT in 6 hours.family declines (follow up CT).impression fall.closed head injury.acute nonintractable (treatable) headache.The change of condition note dated December 21, 2025, at 5:00 p.m., indicated .at 1620 (4:20 p.m.) CNA and nurse discussed discoloration (eye discoloration).notified RN (Registered Nurse) of findings.PM (evening) CNA reports AM (morning) CNA reported around 8:30 a.m., discoloration.MD notified at 16:37 p.m. (4:37 p.m.).stat x-ray to orbital (eyes) bilaterally (both) neuro checks.The nurse note dated December 22, 2025, at 8:27 a.m., indicated .resident assessed by RN supervisor.x-ray unable to be completed.Resident would not stay still for x-ray.resident sent to (named hospital). The physician order dated December 22, 2025, indicated .May send out to hospital for orbital head x-ray.On December 26, 2025, at 3:10 p.m., a concurrent interview and
record review was conducted with the Director of Nursing (DON). The DON stated whenever a resident is found on the floor it is considered a fall. The DON stated the facility process for falls is for nursing to document a change of condition and an IDT meeting is conducted to develop a plan of care for the resident. The DON stated 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 DON stated Resident 1 had six falls without injury, occurring on October 4 and October 10, 2024; November 7, 2024; December 4, 2024; February 19, 2025, and March 3, 2025. The DON also stated Resident 1 had two other documented falls that resulted in injury, on May 13 and December 21, 2025. A review of Resident 1's care plans dated October 10, 2024, and November 7, 2024, was conducted. The DON stated both care plans indicated check and change Resident 1 every 2 hours. The DON stated there was no documented evidence Resident 1 was being checked and changed every 2 hours. The DON stated there should be documentation of nursing checking and changing the resident every 2 hours.Resident 1's care plan dated March 14, 2025, and May 13, 2025, was reviewed. The DON stated the care plan dated March 14, 2025, indicated frequent monitoring and the care plan dated May 13, 2025, indicated monitoring every 30 minutes. The DON stated 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 DON stated there should have been documentation of Resident 1's monitoring. The DON further stated Resident 1's falls were avoidable if nursing had been frequently monitoring Resident 1 as indicated in the care plan.
The DON stated the facility did not follow its own policies and procedures for keeping Resident 1 safe.A
review of the facility policy and procedure titled, Safety and Supervision of Residents, revised July 2017, indicated .The care team shall target interventions to reduce individuals risk related to hazards in the environment including adequate supervision.Implementing interventions to reduce accident risk and hazards shall include the following.ensuring that interventions are implemented.
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If continuation sheet
MEADOWBROOK POST ACUTE in HEMET, 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 HEMET, 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 MEADOWBROOK POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.