Inspection·December 30, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few shift. CNA 1 stated she should have reported Resident 1's swollen eyes to the LVN prior to the shift change.During an interview on December 24, 2025, at 12:59 p.m., CNA 2 stated she was Resident 1's assigned CNA during the evening shift (3-11 pm) on December 21, 2025. CNA 2 stated she was informed by CNA 1 of Resident 1's eyes being swollen and purple. CNA 2 stated she informed the LVN. CNA 2 further stated Resident 1 is uncontrollable and the CNAs have reported it to the Assistant DSD (Director of Staff Development) who stated the resident is ok to come out of bed and that she could not be restrained. CNA 2 stated Resident 1 has never been assigned a one-on-one sitter even though the CNAs keep informing the DON (Director of Nursing) and the (DSD) Director of Staff Development that Resident 1 keeps getting hurt and getting out of bed.On December 24, 2024, Resident 1's medical records were reviewed.Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of intellectual functioning), anxiety (excessive worry or fear), and history of falls.The history and physical completed on July 15, 2024, indicated Resident 1 does not have capacity to make decisions.The BIMS (brief interview for mental status) score dated October 20, 2025, indicated .severely impaired.The care plans were reviewed and indicated the following: -November 7, 2024, .resident has an actual unwitnessed fall.intervention.CNA to check and change resident every 2 hours and as needed.There was no documented evidence in Resident 1's medical record of Resident 1 being checked and changed by the CNAs every 2 hours.-March 14, 2025, .expected behavior related to movement to floor mat.history of falls.per daughter patients cultural (sic) is to sit on the floor every day and do activities and task.intervention.frequent visual monitoring.There was no documented evidence in Resident 1's medical record of Resident 1 having frequent visual monitoring.In addition, there was no documented evidence found in Resident 1's nursing progress notes for the months of March 2025 through December 2025 of frequent visual monitoring of Resident 1 as indicated in the care plan dated March 14, 2025.-May 13, 2025, .resident has an actual unwitnessed fall.goal.resident checked every 30 min and prn (as necessary).resident will be free of falls.There was no documented evidence in Resident 1's medical record of Resident 1 being checked every 30 minutes.In addition, there was no documented evidence found in Resident 1's nursing progress notes for the months of March 2025 through December 2025 of Resident 1 being checked every 30 minutes as indicated in the care plan dated May 13, 2025.The change of condition notes and nursing notes were reviewed and indicated Resident 1 had eight falls which occurred on the following dates:-October 4, 2024, at 4:30 p.m., .resident found sitting on the floor mat beside bed no injuries.md and daughter notified.-October 10, 2024, at 9:30 a.m., .resident was wet and therefore climbed out of bed.instructed CNA to check resident often to be sure resident is clean and dry.MD and daughter notified.-November 7, 2024, at 11:20 a.m., .resident was wet therefore climbed out of bed .instructed CNA to check resident often to be sure resident is clean and dry.MD and daughter notified.-December 4, 2024, at 9:31 a.m., .resident had an unwitnessed fall today at 8:00 a.m. bed was in lowest position floor mat in place.resident found sitting on her mat.MD and daughter notified.-February 19, 2025, at 10:46 a.m., .resident crawled out of bed onto floor mat.MD notified.daughter notified.-March 3, 2025, at 11:45 a.m., .resident was found in her room on her buttocks on floor around 10:40 a.m., md notified.daughter notified.-May 13, 2025, at 18:00 (6:00 p.m.) .fall.skin contusion (bruise).skin tear.top of scalp hematoma.top of scalp.skin tear.contusion .skin tear left side of forehead.neuro checks (assessment of nervous system).resident found on the floor bedside with lower part of body on floor mat.lower part of body on bare floor.head to toe assessment conducted noted with contusion/hematoma and skin tear on left side of forehead.assisted into bed and medicated for pain.MD notified.recommendations.neuro checks.skin care.clean skin tear with NS (normal saline).apply TAB (triple antibiotic ointment).medicate for pain.notified RP.The nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Post Acute 461 E. Johnston Avenue Hemet, CA 92543 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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. Event ID: Facility ID: 055401 If continuation sheet Page 3 of 3