Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure a resident (Resident 1) was free from a
physical restraint when a lap tray was used to keep Resident 1 from falling out of the wheelchair.
Residents Affected - Few
This deficient practice had the potential to increase Resident 1's risk for injury and potentially a further
decline in mobility.
Findings:
Resident 1 was admitted to the facility on [DATE] with a diagnoses that included traumatic brain injury
(TBI).
On 7/18/23 at 8:51 A.M., a review of Resident 1's MDS (a health status screening and assessment tool),
dated 11/21/22, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 14 out of
15, indicating cognition is intact.
On 7/17/23 at 3:14 P.M., an observation of Resident 1 in his room was conducted. Resident 1 was
observed sitting in a high back wheelchair leaning forward with his arms supported by a black padded
board. The black padded board was laying across the resident and attached with two Velcro straps to the
left and right arm rest. Resident 1 was not wearing shoes or non-slip socks and his feet were dangling
unsupported.
On 7/17/23 at 3:15 P.M., an observation and interview was conducted in Resident 1's room with LN 21. LN
21 stated, Resident 1 had a stroke and was totally dependent on staff for his needs. LN 21 stated, the table
attached to the wheelchair prevented Resident 1 from sliding and falling out of the chair. LN 21 stated,
Resident 1's mobility was restricted because he was not able to remove the table without help from the
staff.
On 7/17/23 at 3:23 P.M., a concurrent observation and interview was conducted with Resident 1 and CNA
21 in Resident 1's room. CNA 21 stated, Resident 1 was always in the wheelchair. CNA 21 stated, Resident
1 was not able to remove the lap table and get out of the wheelchair by himself. CNA 21 asked Resident 1
to try and remove the lap table on his own. Resident 1 stated, no when asked if he was able to remove the
table to get out of the wheelchair. CNA 21 stated, Resident 1 could slide out of the chair without the table
when he got agitated.
On 7/19/23 at 12:50 P.M., a telephone interview with Resident 1's resident representative (RR) was
conducted. The RR stated the tray table kept Resident 1 from falling out of the wheelchair. The RR
(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 13
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
07/20/2023
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 0604
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
stated, Resident 1 had previously fallen out of the wheelchair when he sneezed and had to go to the
hospital.
On 7/20/23 at 10:37 A.M., an interview with the director of nursing (DON) was conducted. The DON stated,
a restraint is considered anything that restricts or impedes a resident's movement. The DON stated, it would
be a safety issue and considered a restraint if the resident could not remove the object or device restricting
movement. The DON stated, a doctor's order is required for a restraint and the expectation is that restraints
are monitored for safety.
A record review of Resident 1's physician orders for July 2023, signed 7/12/23, indicated Resident 1 did not
have an order for a wheelchair table, lap tray or any other adaptive physical device. The record did not
indicate Resident 1 had an order for a restraint.
A record review of Resident 1's most recent physical therapy evaluation, signed by the medical doctor on
1/27/21, indicated Resident 1 had impaired ROM and was unable to balance himself while sitting. The
record indicated a wheelchair mobility assessment had not been completed and the record did not indicate
a wheelchair table or lap tray was recommended for positioning.
A record review on 7/20/23 did not indicate a care plan was in place for a wheelchair table, lap tray or any
other adaptive physical device.
A review of the facility policy titled, Use of Restraints, revised April 2017, indicated, Policy Statement .
Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff
convenience, or for the prevention of falls .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 2 of 13
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
07/20/2023
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide alternative language accommodations
for 3 of 18 sampled residents; (Residents 1, 49, and 45), who had been identified to need alternative
communication.
Residents Affected - Few
This deficient practice had the potential to affect Residents (1, 49, and 45) care and accomedations not
being met.
Findings:
1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury
(TBI), and epilepsy (a seizure disorder) per the facility facesheet.
On 7/17/23 at 11:17 A.M. an observation and interview with Resident 1 was conducted in Resident 1's
room. Resident 1 was observed making sounds with his mouth but was unable to verbalize clear sentences
when responding to a question. No communication tools were observed in Resident 1's room or bedside.
Resident 1's speech was incomprehensible and unclear.
On 7/18/23 at 8:51 A.M., a review of Resident 1's MDS (a health status screening and assessment tool),
dated 11/21/22, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 14 out of
15, indicating cognition is intact.
On 7/20/23 at 8:49 A.M., an interview was conducted with CNA 22. CNA 22 stated she could only
understand a few of the words Resident 1 tried to say when he spoke. CNA 22 stated she had not used a
communication aide or tool when providing care for Resident 1. CNA 22 stated the facility had a
communication board available to help residents who had trouble expressing their needs due to language
barriers. CNA 22 stated a communication board could be helpful to better understand Resident 1's needs.
On 7/20/23 at 9:21 A.M., an interview was conducted with LN 23. LN 23 Stated Resident 1 was not able to
verbalize words clearly. LN 23 stated she assessed Resident 1's needs by asking yes or no questions. LN
Stated she had not used a communication board or other communication tools when caring for Resident 1.
LN 23 stated a communication board could be helpful in determining what Resident 1 may be trying to say
while speaking. LN 23 stated being able to communicate your needs is part of being human and all
residents should be given the tools to express themselves.
A record review of Resident 1's speech therapy evaluation, dated 2/8/23, indicated Resident 1 had a past
medical history of cerebellar ataxia (disease or injury to part of the brain that controls muscle movement).
A record review of Resident 1's occupational evaluation, dated 1/3/21, indicated Resident 1's baseline
slurred speech.
A review of Resident 1's activity care plan, reviewed July 2023, needs to be given time to make needs
known .voice weaker now.
2. Resident 49's admission record indicated Resident 49 was admitted on [DATE] under hospice care
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 3 of 13
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
07/20/2023
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 0676
(end of life care) with a diagnosis of depression and bilateral hearing loss (loss of hearing in both ears).
Level of Harm - Minimal harm
or potential for actual harm
A record review of Resident 49's admission assessment, dated 6/20/23 indicated Resident 49's preferred
language was Chaldean (a Aramaic language).
Residents Affected - Few
On 7/20/23 at 8:53 A.M., an interview was conducted with CNA 22. CNA 22 stated Resident 49 did not
speak English. CNA 22 stated she did not know what language Resident 49 spoke. CNA 22 stated the
facility had visual cue cards and communication boards in other languages, but she had not used any of
these tools to communicate with Resident 49. CNA 22 stated she was not aware if the facility had access to
a language line or interpreter because she had never utilized that service.
On 7/20/23 at 9:18 A.M., an observation and interview were conducted with Resident 49 who's primary
language was Chaldean. A communication board with English words was laying on Resident 49's bedside
table. Resident 49 shook her head no when shown the communication board and asked if she could read
the words.
On 7/20/23 at 9:21 A.M., an interview with LN 23 was conducted. LN 23 stated she thought resident 49
spoke Arabic. LN 23 stated she had never used a language line or translation tool to speak to Resident 49
in Arabic. LN 23 stated if the family is not there to interpret for Resident 49 she will use hand gestures to
point and communicate with Resident 49. LN 23 stated the facility had communication boards that have
simple commands and pictures in different languages that are used to communicate with residents. LN 23
stated she was not aware if the facility had a communication board in Arabic.
3. Resident 45 was admitted to the facility on [DATE] with diagnoses of major depressive disorder and
dysphagia per the facility facesheet.
A review of Resident 45's quarterly MDS assessment, dated 7/22/23, indicated resident's preferred
language was Korean and would like an interpreter to communicate with staff.
A review of Resident 45's social services evaluation (SSE), dated 7/19/23, indicated Resident 45 needed
an interpreter.
On 7/20/23 at 9:02 A.M., and interview was conducted with CNA 22. CNA 22 stated Resident 45 spoke
Korean. CNA 22 stated she did not use any communication tools to interact with Resident 45. CNA 22
stated she knew when Resident 45 wanted something because Resident 45 became angry and yelled in
Korean. CNA 22 Stated she had not thought of using an interpreter or language line because she knew
Resident 45's routines.
On 7/20/23 at 9:27 A.M., and interview with LN 23 was conducted. LN 23 stated Resident 45 spoke Korean.
LN 23 stated she knew when Resident 45 was not understanding her because Resident 45 got upset and
yelled in Korean. LN 23 stated she does not speak Korean and had not used an interpreter or a
communication board with Resident 45. LN 23 stated a communication board could be helpful to help try to
understand the reasons for Resident 45 agitation.
On 7/20/23 at 9:28 A.M., an interview with the activities director (AD) was conducted. The AD stated the
facility did not have communication boards in Korean and Arabic. The AD stated it was important to have a
communication board at the bedside in the resident's preferred language.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 4 of 13
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
07/20/2023
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 0676
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 7/20/23 at 10:37 A.M., an interview with the DON was conducted. The DON stated the expectation for
communicating with residents was that staff use all the available tools to understand the needs of each
resident. The DON stated the facility does not have a language line available for staff to use but they can
use their personal phones if they want to use a translation application. The DON stated if a resident
becomes visibly frustrated and they speak a language other than English an attempt to communicate in
their native language should be made with the tools available. The DON stated the expectation is that all
Residents have an assessment of communication skills and verbal skills as part of admission.
A record review of the facility assessment was conducted on 7/19/23 at 8:35 A.M., The Facility Assessment
indicated the facility would place non-English-speaking residents with staff who speak the same language,
ask family members to stay and use the language line or Google translate.
A request for the facility communication policy and procedure was requested, and none was provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 5 of 13
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
07/20/2023
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 a resident (Resident 12) safely
consumed administered medications when medications were found in Resident 12's bedside drawer.
This deficient practice had the potential to put the health and safety of all residents at risk.
Findings:
Resident 12 was admitted to the facility on [DATE] with diagnoses that included heart failure and atrial
fibrillation (a chronic progressive condition that affects the heart) per the facility facesheet.
On 7/17/23 at 12 P.M., an observation and concurrent interview were conducted with Resident 12 in her
room. Resident 12 opened the bedside table drawer and removed two clear plastic medication cups which
contained 5 pills:
1. Two small round peach-colored tablets
2. One small round reddish/brown colored tablet
3. One medium round white colored tablet
4. One medium oblong purple color tablet
Resident 12 stated, four of the pills were from the morning medication administration (7/17/23 A.M.) and
one of the pills was from lunch time the previous day 7/16/23. Resident 12 stated, she did not like to take
her morning medications until after lunch because the medication upset her stomach.
On 7/17/23 at 12:31 P.M., an observation, interview and record review was conducted with licensed nurse
(LN) 22. LN 22 stated she administered Resident 12's morning medications that was scheduled at 9 A.M.
LN 22 walked to Resident 12's room; Resident 12 opened her bedside table and LN 12 validated the
following: 2 medication cups with 5 pills were in Resident 12's drawer. LN 22 stated, it was the expectation
for nurses to observe residents take all their administered medications and that LN 22 should not have left
Resident 12's morning medications at the bedside. In a review of Resident 12's MAR, LN 22 stated, the five
pills in the cup to be the following:
1. Aspirin 81mg chewable, give two tablets(162mg) by mouth daily for deep vein thrombosis prophylaxis
(small round peach color). Last administered 7/17/23 at 9 A.M.
2. Ferrous sulfate 325mg tablet, one by mouth twice a day for anemia (small round reddish/brown color).
Last administered 7/17/23 at 9 A.M.
3. Vitamin C 500mg tablet, one tablet by mouth daily for supplement. (medium round white color). Last
administered 7/17/23 at 9 A.M.
4. Movantik 25mg tablet, one tab by mouth daily at noon for bowel management
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 6 of 13
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
07/20/2023
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
(medium oblong purple color). Last administered 7/16/23 at noon.
Level of Harm - Minimal harm
or potential for actual harm
The MAR indicated LN 22 had administered the aspirin, the ferrous sulfate and the vitamin C at 9 A.M. on
7/17/23. LN 22 stated, the Movantik was from a previous administration as it was not a morning medication
she had administered. LN 22 disposed of the medication cup containing the five (5) bedside medications in
the medication waste bin. LN 22 stated, medications should not be left at the bedside because it is not an
acceptable practice and could be accessed by others.
Residents Affected - Few
On 7/20/23 at 2:13 P.M., an interview and record review with the director of nursing (DON) was conducted.
The DON stated, LN 22 should have watched Resident 12 swallow her medications. The DON stated, it was
a safety issue for all residents if medications were left unconsumed at the bedside. The DON stated, the
MAR should accurately reflect what medications were consumed by the resident at the time the nurse
administered the medications to the resident.
A review of the facility policy titled Administering Medications, revised April 2019, indicated Policy
Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy
Interpretation and Implementation . 21. If a drug is withheld, refused, or given at a time other than the
scheduled time, the individual administering the medication shall initial and circle the MAR space provided
for that drug and dose . 27. Residents may self-administer their own medications only if the Attending
Physician, in conjunction with the Interdisciplinary Are Planning Team, has determined that they have the
decision-making capacity to do so safely.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 7 of 13
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
07/20/2023
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure a physicians' order for oxygen therapy
was followed for 1 of 18 sampled residents, Resident 10.
Residents Affected - Few
As a result, Resident 10 did not receive oxygen therapy as ordered.
Findings:
Resident 10 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure
(a progressive lung disease that makes it difficult to breathe), per the facility's Face Sheet.
On 7/18/23 at 8:51 A.M., a review of Resident 10's MDS (a health status screening and assessment tool),
dated 6/11/23, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 12 out of
15, indicating mild impairment of cognition.
On 7/18/23 at 9:01 A.M., Resident 10 was observed sitting in her wheelchair in front of her room with
oxygen on at 1 1/2 liters per minute (LPM) via nasal cannula (NC) (a plastice tubing connected from the
oxygen tank to the resident's nostrils).
On 7/18/23 at 9:15 A.M., an interview with Resident 10 was conducted. Resident 10 stated she had been
on oxygen at 2 LPM via NC for two years for her breathing problems.
On 7/19/23 at 9:21 A.M., Resident 10 was observed sitting in her wheelchair in front of the nursing station
with oxygen on at 1 1/2 liters per minute (LPM) via nasal cannula (NC).
On 7/19/23 at 9:34 A.M., a review of Resident 10's clinical record was conducted. A physician's order, dated
3/14/23, indicated, Continuous Oxygen at 2 LPM via Nasal Canula.
On 7/19/23 at 9:51 A.M., a review of Resident 10's clinical record was conducted. According to the care
plan, dated 3/15/23, .continuous oxygen 2L/min via nasal canula as ordered.
On 7/19/23 at 10:09 A.M., a concurrent observation of Resident 10 and interview with LN 25 was
conducted. LN 25 confirmed Resident 10 was on 1 1/2 LPM of oxygen instead of the ordered 2 LPM.
On 7/19/23 at 10:28 A.M., a concurrent interview and record review of Resident 10's treatment sheet dated
7/19/23 was conducted with LN 25. LN 25 confirmed Resident 10 should have been on oxygen at 2 LPM.
On 7/19/23 at 2:28 P.M., an interview with the DON was conducted. The DON stated, it is the expectation
for the LN staff to carry out orders as written to ensure residents receive the prescribed treatment.
On 7/19/23 at 3:31P.M., Review of facility policy titled, Administering Medications, dated 12/2012, indicated,
3.Medications must be administered in accordance with the orders, .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 8 of 13
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
07/20/2023
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 0727
Level of Harm - Minimal harm
or potential for actual harm
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on observation, interview and record review, the facility failed to provide a registered nurse (RN) on
duty 8 consecutive hours per day, seven days per week.
Residents Affected - Some
This failure had the potential for more advanced assessments and care activities provided by an RN to be
unavailable to residents.
Findings:
During the initial tour of the facility on 7/17/23 at 10 A.M., there were no RN's observed to be on duty.
During a resident council meeting on 7/18/23 at 9:56 A.M., Resident (4) stated, The staffing schedule was
messed up; weekends are especially hard, staff call off and it makes it hard on residents.
During a resident council meeting on 7/18/23 at 9:10 A.M., seven of seven residents (4,13,25,33,37,51,125)
stated there were lots of registry staff, some are rude and ignore residents, and there are no RN's, only
LVN's.
A review of the facility's document, titled Staffing Assignments, for July 17, July 18 and July 19 2023,
indicated a blank space for the column RN.
A review of the PBJ (payroll based journal) Staffing Data Report, CASPER report 1705D, FY (fiscal year)
Quarter 2, indicated, .triggered: four or more days within the quarter with no RN hours . Further review of
the staffing data report indicated: ' .Infraction dates: 01/07; 01/08; 01/14; 01/15; 01/22; 02/04; 02/05; 02/11;
02/12; 02/18/; 02/25; 02/26; 03/11;03/12; 03/18; 03/19; 03/25; 03/26.
A concurrent interview and record review was conducted with the Director of Nursing (DON) on 7/19/23 at
10:05 A.M. The DON reviewed the staffing assignments and stated, We don't have an RN for 8 hrs a day for
7 days a week, sorry, we just don't. It is too hard to find someone. The DON continued to state, this has
been the case since January (2023), we do not have an RN for 8 hrs a day and we do not have a waiver.
An interview was conducted with the DON on 7/20/23 at 10:15 A.M., The DON stated, It is important to
have an RN on duty because only RN's can do assessments and IV antibiotics.
A review of the Facility Assessment, dated, 3/17/23, indicated, . Part 3: Facility resources needed to provide
competent care and support for our Resident population every day and during emergencies .3.1 Staff Type:
Nursing Services: .Registered Nurses (RN) .
A review of the facility's policy, dated 10/2017, titled, Staffing, indicated, Our facility provides sufficient
numbers of staff with the skills and competency necessary to provide care and services for all residents in
accordance with resident care plans and the facility assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 9 of 13
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
07/20/2023
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review the facility failed to discard a residents' medication from
the medication storage room when the resident was discharged from the facility.
This had the potential risk for other residents to be given the wrong medication.
Findings:
On 7/19/23 at 10:16 A.M., an observation, interview and record review was conducted with LN 24. An
observation of a clear plastic bag containing several small bottles of a liquid Lidocaine (a numbing
medication to reduce discomfort) was found on the counter of the medication storage room. The clear
plastic bag had a pharmacy label that indicated a resident name, a date (10/14/2022) and the resident
room number. LN 24 stated, the medication should not be in the medication storage room. LN 24 stated,
the resident was no longer in the facility per the census. LN 24 further stated, the medication should have
been discarded when the resident was discharged .
On 7/19/23 at 11:33 A.M., an interview with the DON was conducted. The DON stated, it is the expectation
of staff to discard unused medications of any discharged residents to prevent other residents from
potentially being given the wrong medication. The DON further stated, the staff need to follow the facility
policy and procedure.
On 7/19/23 at 2:31P.M., Review of facility policy titled, Disposal of Non - Controlled Medications, no date,
indicated, .(c) Patient drugs supplied by prescription .those which remain in the facility after discharge of
the patient shall be destroyed by the facility .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 10 of 13
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
07/20/2023
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 that all food items were
labeled and dated. In addition, the facility did not ensure that there were no expired food items.
Residents Affected - Some
This failure had the potential for all residents who eat at the facility to become ill due to increased bacteria
growth in the food, and/or have decreased food intake leading to weight loss due to poor food palatability.
Findings:
An initial tour/observation of the facility's kitchen was conducted on 7/17/23 at 9:50 A.M., with the facility's
Dietary Services Manager (DSM).
In the walk in refrigerator, there was a bakers rack with two trays of cappuccino mousse, two trays of fruit
salad, and two trays of lettuce salad with no made-on date nor an expiration date.
In the dry storage area, there were the following items with no expiration date:
Four 6-pound cans of black beans;
Two 6-pound cans of pinto beans;
Two 6-pound cans of sweet potatoes;
Nine 6-pound cans of beef stew.
An interview was conducted with the DSM on 7/17/23 at 10:00 A.M. The DSM stated, The cans have no
expiration date on them. An expiration date is important because it tells us when the food is no longer good,
it can cause stomach trouble for the residents.
An interview was conducted with the administrator (Admn) on 7/20/23 at 9:02 A.M. The Admn stated,
Different manufacturers use expiration codes; we didn't know that.
An interview was conducted with the Director of Nursing (DON) on 7/20/23 at 9:40 A.M. The DON stated,
Expiration dates on food are important because expired food can cause food-borne illness for the residents.
An interview was conducted via telephone with the Registered Dietitian (RD) on 7/20/23 at 9:42 P.M. The
RD stated, Staff need to make sure food is labeled so we know when to get rid of it. Canned foods need an
expiration date, so residents aren't eating spoiled food.
A review of the facility's policy, dated, July 2023,and titled Food Receiving and Storage, indicated, foods
shall be received and stored in a manner that complies with safe food handling ; 9.all foods stored in the
refrigerator or freezer will be covered and labeled and dated (use-by date); 7.any received foods that do not
display an expiration date will be returned to the manufacturer .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 11 of 13
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
07/20/2023
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure infection control practices within the
facility when:
Residents Affected - Few
1. The facility did not ensure a residents oxygen tubing was labeled and dated when last changed. In
additon,
2. The facility did not implement a water management system program.
This lack of infection control practices had the potential to expose a vulnerable population of residents to
harmful organisms.
Findings:
1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory
failure (a progressive lung disease that makes it difficult to breathe), per the facility's Face Sheet.
On 7/18/23 at 8:51 A.M., a review of Resident 10's MDS (a health status screening and assessment tool),
dated 6/11/23, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 12 out of
15, indicating mild impairment of cognition.
On 7/18/23 at 9:01 A.M., Resident 10 was observed sitting in her wheelchair in front of her room with
oxygen on at 1 1/2 liters per minute (LPM) via nasal cannula (NC); no label or date for when tubing was last
changed.
On 7/19/23 at 9:21 A.M., Resident 10 was observed sitting in her wheelchair in front of the nursing station
with oxygen at 1 1/2 liters per minute (LPM) via nasal cannula (NC); no label or date for when tubing was
last changed.
On 7/19/23 at 10:09 A.M., a concurrent observation of Resident 10 and interview with LN 25 was
conducted. LN 25 confirmed that the oxygen tubing had no label or date for when the oxygen tubing was
last changed. LN 25 further stated, she was not sure when the tubing was last changed or how long the
tubing was good for.
On 7/19/23 at 11:43 A.M., an interview with the IPIC nurse was conducted. The IPIC nurse stated, the
oxygen cannula and tubing are changed every seven (7) days. The IPIC nurse further stated, the oxygen
tubing should have had a label on it indicating when it was last changed. The IPIC nurse further stated, it is
important to have a label on the oxygen tubing with the last changed date to prevent potential infection to
the resident.
On 7/20/23 at 1:43 P.M., A Review of the facility policy titled, Respiratory Therapy - Prevention of Infection,
dated 12/2011, indicated, 7.Change the oxygen cannula and tubing every seven (7) days, .
2. On 7/19/23 at 9:47 A.M., an interview was conducted with the IPIC. The IPIC stated the facility had not
assessed, created or implemented a water management program to detect the presence of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 12 of 13
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
07/20/2023
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Legionella; or any other waterborne diseases in the facility. The IP stated it was important to have a water
management program to prevent waterborne illnesses and to keep residents safe.
On 7/19/23 at 11:09 A.M., an interview was conducted with the director of maintenance (DOM). The DOM
stated the facility did not need a water management program because the facility did not have storage
tanks; and the water came directly from the city.
ON 7/19/23 at 11:16 A.M., a concurrent interview and record review was conducted with the facility
administrator (ADMN). The facility document for Legionella and water management system was reviewed.
The ADMN stated, the facility utilized the centers for disease control (CDC) guidance for implementing
industry standards which was included in the document for Legionella. The ADMN stated the facility
assessed a need for a water management program by filling out page 2 of the document, Developing a
Water Management Program to Reduce Legionella Growth and Spread in Buildings: A Practical Guide to
Implementing Industry Standards, dated June 5, 2017. titled Identifying Buildings at Increased Risk. (IBIR).
A review of page 2 of the IBIR indicated, the facility marked yes to a need for a water management program
for the facility's hot and cold-water distribution system. The facility did not have a water management
program implemented.
On 7/19/23 at 3 P.M. an interview with the DON was conducted. The DON stated the facility did not have a
water management program that tests for Legionella because the facility is not high risk for Legionella.
DON further stated that they are not responsible for testing the water because the facility water source
comes from the city.
On 7/20/23 at 3:43 P.M., A Review of the facility policy titled, Legionella Water Management Program,
revised July 2017, indicated, Policy Statement: Our facility is committed to the prevention, detection and
control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation: 1. As
part of the infection prevention and control program, our facility has a water management program that is
overseen by the water management team . 3. The purposes of the water management program are to
identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of
Legionnaire's disease .5. The water management program includes the following elements .b. A detailed
description and diagram of the water system in the facility . c. The identification of areas in the water system
that that could encourage the growth and spread of Legionella or other waterborne bacteria . d. The
identification of situations that can lead to legionella growth . e. Specific measures used to control the
introduction and/or spread of legionella . f. The control of limits or parameters that are acceptable and that
are monitored . g. A diagram of where control measures are applied . h. a system to monitor control limits
and the effectiveness of control measures . i. A plan for when control limits are not meta and control
measures are not effective . j. Documentation of the program .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055298
If continuation sheet
Page 13 of 13
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Back to topCitations
8 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.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 20, 2023 survey of FALLBROOK SKILLED NURSING?
This was a inspection survey of FALLBROOK SKILLED NURSING on July 20, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FALLBROOK SKILLED NURSING on July 20, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment."
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.