Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure bruising was evaluated and communicated to the
wound treatment nurse for monitoring for one of two residents (45) sampled for anticoagulation (blood
thinner) medication side effects. This failure had the potential for bruising to increase in size without
monitoring and lead to a delay in treatment for Resident 45.
Residents Affected - Few
Findings:
Resident 45 was admitted to the facility on [DATE] with diagnoses, which included end stage heart failure
(weakened heart muscle is unable to pump enough blood) and palliative care (comfort care to treat
symptoms and side effects of serious illnesses), per the facility's Face Sheet.
According to Resident 45's physician orders, dated 7/26/19, the resident received clopidogrel (a blood
thinner that affects blood clotting) daily for blood clot prevention.
According to Resident 45's physician orders, dated 9/5/19, the resident received warfarin (a blood thinner
that counteracts the clotting actions of Vitamin K in the blood).
According to a review of Resident 45's CNA Shower Sheets, on 9/10/19, .Small bruises on R (right) back R
arm, and on 9/17/19, .Her leg is looking purple .
According to a review of Resident 45's Anticoagulant Care Plan, initiated 7/27/19, .Potential for injury:
bleeding r/t (related to) anticoagulation therapy . Approaches: .Report new area of bruising .
A record review of Resident 45's Treatment Administration Record, weekly nursing summary, and nursing
progress notes was conducted with the MDS nurse on 9/18/19 at 9:14 A.M. The MDS nurse stated she did
not see anything in Resident 45's records to indicate she had any current bruising.
During an interview with LN 4 on 9/18/19 at 11 A.M., LN 4 stated Resident 45 was started on a second
blood thinner on 9/5/19 and it was important for any signs or symptoms of bleeding to be monitored.
During an interview with the wound treatment nurse (tx nurse) on 9/18/19 at 11:36 A.M., the tx nurse stated
Resident 45 had bruising on her arms and left lower leg when admitted on [DATE], which were all resolved
on 8/24/19. The tx nurse stated she was not aware of the bruising described on the 9/10 and 9/17/19 CNA
shower sheets. The tx nurse stated the nursing progress notes and summary for those dates should have
included the bruising identified by the CNA on the shower sheets, and should
(continued on next page)
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
Page 1 of 8
Event ID:
055298
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
055298
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fallbrook Skilled Nursing
325 Potter Street
Fallbrook, CA 92028
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 0684
have been reported to the tx nurse for monitoring.
Level of Harm - Minimal harm
or potential for actual harm
During an interview with the DON on 9/18/19 at 1:49 P.M., the DON stated any bruising identified by the
CNA should have been reported to the charge nurse, and the resident should have been monitored for
bruising. The DON stated it was important for residents on anticoagulants to be monitored for any signs of
internal bleeding.
Residents Affected - Few
According to a review of the facility's undated policy titled Orders for Anticoagulants, .Orders for
anticoagulants shall be prescribed only with proper clinical . monitoring . 4. Nursing Services must notify the
physician if the resident has any signs or symptoms of internal bleeding such as hematuria (blood in urine)
or excessive bruising .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 2 of 8
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
055298
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fallbrook Skilled Nursing
325 Potter Street
Fallbrook, CA 92028
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one of five residents (3) investigated
for falls, had an interdisciplinary team (IDT) meeting (to discuss and implement an updated care plan)
following a fall. This had the potential to contribute to additional falls with injury for Resident 3, and
miscommunication among health care providers.
Findings:
Resident 3 was admitted to the facility on [DATE] with diagnoses, which included non-traumatic subdural
hemorrhage (bleeding into the brain not caused by external injury) and dementia (a loss of mental abilities
that leads to impairments in memory, reasoning, planning, and behavior), per the facility's Face Sheet.
According to a review of Resident 3's physicians order, dated 5/31/19, the resident was admitted to the
facility following a fall.
According to a review of Resident 3's Fall Risk Assessments, dated 5/31 and 9/6/19, the resident was at
high risk for falls.
On 9/15/19 at 12:36 P.M., Resident 3 was observed lying in bed under the covers with family members at
his bedside. The resident's bed was in the lowest position; a landing mat was on the floor next to the bed,
with a bed pressure alarm (a device to alert staff if resident attempts to get out of bed) in place. Resident
3's family member stated the resident had a few falls since his admission, with the most recent one a few
weeks ago where he bumped his head falling out of his wheelchair while he was at the nursing station. A
small lump approximately the size of a quarter with light green-yellow bruising was observed on the left top
and side of the resident's forehead, approximately one inch above his eyebrow.
During an interview with CNA 1 on 9/17/19 at 2:11 P.M., CNA 1 stated Resident 3 was a fall risk and would
try to get up on his own when he got confused. CNA 1 stated the resident did not use the call light and they
needed to check on him frequently.
According to a review of Resident 3's nursing progress notes, dated 9/8/19, the resident had a witnessed
fall out of his wheelchair onto his knees and then hit his head on the floor.
According to a review of Resident 3's care plan, initiated 5/31/19, the resident was at risk for falls and injury.
This care plan was last updated on 8/26/19 and indicated Resident 3 had actual falls on 7/6 and 8/26/19.
This care plan did not indicated Resident 3 had a fall on 9/8/19.
During a concurrent interview and record review with the MDS nurse on 9/18/19 at 9:27 A.M., the MDS
nurse stated she was part of the IDT that met after a resident had a fall. The MDS nurse stated the IDT
included the DON, case manager, social services, and physical therapy. The IDT met after a resident had a
fall to review the incident and determine the reason and find new interventions to prevent further falls. The
MDS nurse stated Resident 3 had a few falls, but she did not see an IDT note or remember an IDT for the
fall documented on 9/8/19. The MDS nurse stated nursing or any member of the IDT should update the
resident's care plan after a fall.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 3 of 8
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
055298
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fallbrook Skilled Nursing
325 Potter Street
Fallbrook, CA 92028
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 - Minimal harm
or potential for actual harm
During a concurrent interview and record review with LN 4 on 9/18/19 at 10:50 A.M., LN 4 stated when a
resident had a fall, an incident report was completed and turned into the DON. LN 4 stated the IDT then
followed up on the resident's fall. LN 4 stated he witnessed Resident 3's fall on 9/8/19. LN 4 stated he
should have updated the care plan to include the fall on 9/8/19. LN 4 stated after the IDT met they would
also update the care plan with any new interventions identified at the IDT meeting.
Residents Affected - Few
During an interview with the DON on 9/18/19 at 1:54 P.M., the DON stated after a resident had a fall,
nursing was supposed to create an incident report so that the DON could review the fall with the IDT the
next day. The DON stated the IDT would attempt to determine the cause of a fall and recommend
interventions to prevent the resident from having further falls. The DON stated Resident 3's care plan
should have been updated by the nurse, MDS, or the IDT. The DON stated she was working on a better
process to communicate falls to the IDT.
According to a review of the facility's undated policy titled Assessing Falls and Their Causes, Purpose: The
purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in
identifying causes of the fall . General Guidelines: .5. Resident must be assessed in a timely manner for
potential causes of falls . Steps in the Procedure: .3. Identifying Causes of a Fall or Fall Risk: a) Within 24
hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident . b) Staff
will evaluate chains of events or circumstances preceding a recent fall . c) The staff will continue to collect
and evaluate information until they either identify the cause of falling or determine that the cause cannot be
found .
According to a review of the facility's policy titled Fall Risk Assessment, dated 3/00, Policy Statement: It is
the policy of this facility to assess residents for risk of falls, to follow up and evaluate all falls of residents in
order to assess the individual's condition, to identify the reason for the fall and prepare a plan of care to
reduce the potential for future falls . Monitoring: 7. A care plan 'Status Post Fall' will be added to the
permanent care plan. The circumstances of the fall will be addressed .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 4 of 8
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
055298
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fallbrook Skilled Nursing
325 Potter Street
Fallbrook, CA 92028
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure LNs followed their policy and
procedure for checking the medication label for the expiration date prior to administering for one randomly
sampled resident (276). As a result, Resident 276 received two doses of an expired medication.
Findings:
Resident 276 was admitted to the facility on [DATE], with diagnoses to include anemia (decreased amount
of red blood cells in the body), per the facility's Face Sheet. Resident 276's admission physician orders
included folic acid (vitamin important to red blood cell production) 1 mg daily.
On 9/17/19 at 8:45 A.M., during a medication observation, LN 5 prepared and administered 11 medications
to Resident 276, including folic acid 1 mg.
On 9/17/19 at 9:25 A.M., LN 5 was interviewed. LN 5 inspected Resident 276's folic acid bubble pack
(method of packing medications, where each dose was placed in a small plastic bubble and backed by a
sheet of foil and cardboard) and pharmacy label. LN 5 stated the label indicated the medication expired on
4/30/19. LN 5 stated I gave an expired med. LN 5 further stated she had administered the folic acid to
Resident 276 on 9/16/19, using the same bubble pack.
On 9/17/19 at 1:35 P.M., LN 6 was interviewed. LN 6 stated LNs were responsible for checking the
medication labels for accuracy and expiration dates. LN 6 stated the folic acid should not have been
administered to Resident 276.
According to the undated facility's policy, Administering Medications, . 8. The expiration date on the
medication label must be checked prior to administering.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 5 of 8
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
055298
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fallbrook Skilled Nursing
325 Potter Street
Fallbrook, CA 92028
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure food was prepared and
stored in accordance with professional standards of food service safety when:
Residents Affected - Some
1. Proper food cool down procedures were not followed.
2. Two resident unit refrigerator temperatures were not consistently monitored. Food in one refrigerator was
unlabeled and undated, and one refrigerator was not clean.
These failures had the potential for bacterial growth in resident's food and placed residents at risk for food
borne illness.
Findings:
1. During an initial tour of the kitchen on 9/15/19 at 9:36 A.M., cook 1 stated the book where the cool down
log was kept had been updated, therefore there was no current cool down log. [NAME] 1 stated she cooked
a beef roast this morning, which was removed from the oven at approximately 7 A.M., and placed in the
freezer for cool down. [NAME] 1 stated the roast was moved from the freezer just before 9 A.M. and placed
in the refrigerator.
On 9/15/19 at 9:40 A.M., a pan of roast beef was observed on the middle shelf of the walk-in refrigerator
covered with foil, which was dated 9/15/19. [NAME] 1 checked the temperature of the roast, which was 43.3
degrees (°) Fahrenheit (F). [NAME] 1 stated she recalled the temperature was approximately 48°
F when she moved the roast out of the freezer. [NAME] 1 stated she should have written down the times
and temperatures on a piece of paper until she could find the cool down log.
During an interview with the DSS on 9/16/19 at 11:20 A.M., the DSS stated cook 1 should have written the
times and temperatures for the roast beef on a plain piece of paper until she found the new cooling log.
According to a review of the facility's previous cool down logs, on 6/11/19, roast beef was 160° F at 7
A.M., and 120° F at 9 A.M.
During a concurrent interview and review of previous cool down logs on 9/16/19 at 11:21 A.M., the DSS
stated the cool down log on 6/11/19 indicated at two hours the roast beef had not been cooled to or below
70° F. The DSS stated if the temperature of the roast beef on 6/11/19 was 120° F after two hours
of cool down, the food should have been reheated to 165° F and the cool down process started again.
The DSS stated the cool down log did not indicate the food was reheated as it should have been.
On 9/16/19 at 12:18 P.M., the DSS stated it was important to document the times and temperatures on the
cool down log and to properly follow cool down protocol to prevent food contamination and keep residents
from getting sick.
According to a review of the facility's policy titled Cooling and Reheating Potentially Hazardous Foods,
dated 2015, Policy: Cooked potentially hazardous foods shall be cooled and reheated in a method to
ensure food safety . The Two-Stage Method:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 6 of 8
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
055298
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fallbrook Skilled Nursing
325 Potter Street
Fallbrook, CA 92028
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 0812
•
Level of Harm - Minimal harm
or potential for actual harm
Cool cooked food from 140° F to 70° F within two hours.
•
Residents Affected - Some
Then cool from 70° F to 41° F or less in an additional four hours for a total cooling time of six
hours .
•
When cooling down food, use the Cool Down Log to document proper procedure.
.Take corrective action as follows: Reheat cooked, hot food to 165° F for 15 seconds and start the
cooling process again using a different cooling method when the food is: Above 70° F and 2 hours or
less into the cooling process . Note any corrective action taken on the Cool Down Log .
2. An observation of the resident refrigerator located at nursing station two was made with LN 1 on 9/17/19
at 3:24 P.M. A partially eaten pie and a covered container filled with chunks of watermelon were in the
refrigerator without a resident name or date labeled on the containers. LN 1 stated all food needed to be
labeled with a resident name and dated so that they knew when the food expired to prevent residents from
getting sick from eating spoiled food. LN 1 also stated the refrigerator temperature needed to be checked
and documented on the log. LN 1 was unable to find the temperature log.
An observation of the resident refrigerator located in the charting room across from nursing station one was
made with LN 2 on 9/17/19 at 3:28 P.M. The temperature inside the resident refrigerator read 50° F.
The plastic bin at the bottom of the refrigerator was covered with a beige colored substance on the top and
down the sides of the bin. LN 2 stated it looked like something had spilled. LN 2 also stated she did not
know where the temperature monitoring log was located for the resident refrigerator. LN 2 stated if the
refrigerator was warm the food could spoil and make the residents sick.
According to a review of the resident refrigerator temperature log for nursing station two, temperatures were
monitored sporadically for the month of 4/19, and one temperature was documented on 9/17/19. No
temperature logs were found between 4/19 and 9/19.
During an interview on 9/17/19 at 4:40 P.M., LN 3 stated the clipboard with the temperature logs had been
moved from the refrigerator, and was found in a different area of nursing station two. LN 3 stated residents
refrigerator temperatures needed to be monitored and recorded daily. During a concurrent interview and
review of the station two resident refrigerator log, LN 3 stated the temperatures had not been monitored
consistently.
During an interview on 9/17/19 at 4:47 P.M., LN 2 stated she was unable to find any temperature logs for
nursing station one's resident refrigerator.
During an interview on 9/18/19 at 11:52 A.M., the Infection Control Nurse (ICN) stated the nursing staff
were expected to monitor and document temperatures of the residents refrigerators on the log for each
refrigerator, and all food should have been labeled with the resident name and dated. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 7 of 8
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
055298
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fallbrook Skilled Nursing
325 Potter Street
Fallbrook, CA 92028
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 0812
Level of Harm - Minimal harm
or potential for actual harm
ICN stated if the refrigerator temperatures were not in the correct range, or if the food was stored too long,
it increased the risk for residents to develop food borne illness.
During an interview with the Maintenance Supervisor (MS) on 9/18/19 at 11:54 P.M., the MS stated
housekeeping cleaned the residents refrigerators monthly and tossed any old or unlabeled food.
Residents Affected - Some
During an interview with the MS on 9/18/19 at 12:03 P.M., the MS stated the nursing staff were supposed to
be monitoring and logging refrigerator temperatures and report to him if the temperatures were out of
range. The MS stated he had a communication book at each nursing station that he checked every two
hours, and the nurses called him directly with any issues that needed immediate attention. The MS stated
he was not aware the resident refrigerators were not monitored or out of range.
During an interview with the DON on 9/18/19 at 1:58 P.M., the DON stated she did find more temperature
logs for August and September. The DON stated there were a number of gaps in those logs, and stated the
refrigerator temperatures were not monitored consistently. The DON stated it was important to monitor
refrigerator temperatures daily to ensure the temperatures were in the proper range so they would not
harbor bacteria. The DON stated food in resident refrigerators needed to be labeled with the resident
names and dated for the same reason.
According to a review of the facility's document titled Temperature Log Refrigerator, .Instructions: Record
temperature daily . If temperature is not in acceptable range [31° to 43° F], record corrective
action taken (i.e. adjusted temperature, engineering notified, etc.) in space below corresponding date .
According to a review of the facility's undated policy titled Foods Brought by Family/Visitors, .Storing
Perishable Foods: 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the
refrigerator. Containers will be labeled with the resident's name, the time and the 'use by' date. Discarding
perishable Foods: 7. The nursing staff is responsible for discarding perishable foods on or before the 'use
by' date .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 8 of 8
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the September 18, 2019 survey of FALLBROOK SKILLED NURSING?
This was a inspection survey of FALLBROOK SKILLED NURSING on September 18, 2019. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FALLBROOK SKILLED NURSING on September 18, 2019?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.