Health inspection·September 18, 2025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 667mg, give two tablets three times a day, at 7 A.M., 1 P.M., and 5 P.M.For the month of August 2025, there were 93 opportunities for this medication to be given. 12 times the medication was not given, with a reason - see progress notes, which reflected Resident 1 was at dialyis. Resident 3 physician orders included an informational order that resident 3 went to dialysis on Tuesdays, Thursdays, and Saturdays, with a pick up time of 1:30 P.M., and a return time of 6:45 P.M; and medication orders for: Hydralazine (a medication for high blood pressure) 100mg two times a day at 9 A.M., and 5 P.M.In August 2025, there were 62 opportunites for this medication to be given; 24 opportunities were missed, the medication was not given. The reasons documented were hold - see progress notes and Other-see progress notes with 3 reasons as hospitalized . The missed doses were Tuesday, Thursday and Saturday, 15 times at the 5 P.M. time, and 8 times at the 9:00 AM times. One dose was marked NA, but checked as given on Friday, 8/23/25. On six days, (Aug. 2, 12, 14,16, 21, and 26) Residnet 3 did not receive any of this medication.Resident 3 also has a physician order, dated 1/20/25, for Carvedilol (a medication for both high blood pressure or an irregular heart beat), 25mg orally twice a day for high blood pressure with directions to hold (not give) if Resident 3's blood pressure was less than 100 or his heart rate was less than 60. Out of 62 opportunities for this medication to be given, it was omitted 17 times, with reasons documented as other/hold - see progress notes 15 times; in hospital three times; and vitals outside of parameter one time.Resident 4 physician orders included: an informational order that resident went to dialysis on Tuesdays, Thursdays, and Saturdays, and pick up time was 1 P.M. No return time was listed.Resident 4 had medication orders including: Isosorbide Mononitrate ER 60mg (a blood pressure medication) give once daily for hypertension, hold if blood pressure less than 100 or heart rate (beats per minute) less than 60. Out of 31 opportunities, the record is blank for August 1, the medication was not given due to Resident 4 refusing three times, and was held as outside of parameters once. The medication was given in error on August 10, 2025 when Resident 4's heart rate was below 60 (58).LN 1 was interviewed on 9/18/25 at 12:30 P.M. and stated Resident 1 recently had the dialysis pick up time changed, and he misses one dose of his blood pressure medications when he is out. LN 1 stated for fully oriented residents, he would give the medication to go with them and take with their lunch, but he does not do that for Resident 1, does not feel he would remember to do it. LN 1 stated he had not notified the doctor regarding the missed doses, or let the charge nurse know so they could notify the doctor. LN 1 stated Resident 1 could have problems, like increased signs of high blood pressure, for missing a dose.The DON was interviewed on 9/18/25 at 12:40 P.M. The DON stated it is expected that all residents get their medications as ordered. The DON also stated the issue needed to be worked on by the facility notifying the physician of the missed medications, and clarify whether to change the administration times for the medications or send with the resident to dialysis. This Health Facilities Evaluator Nurse requested any policy regarding sending residents with their medications, and received a policy titled Medication Holds, dated April 2007, that stated temporary edication holds may be ordered by the resident's attending physician, and a policy titled Dispensing Medications to Residewnts on Leave/Pass, dated April 2007, which stated: the facility shall provide resdients with necesary mediication(s) when they leave the facility temporarily. 1. Residents who are away from the facility during medications passes will be given scheduled and essential PRN (as needed) medication(s) to take with them. They will only be given the amounts and dosages needed for the length of the anticipated absence. Event ID: Facility ID: 055298 If continuation sheet Page 2 of 4 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 09/18/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 22 CCR S 72543S 72543. Patients' Health Recordsa) Records shall be permanent, either typewritten or legibly written in ink, be capable of being photocopied and shall be kept on all patients admitted or accepted for care. All health records of discharged patients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until 1 year after the minor has reached the age of 18 years, but in no case less than 7 years. All exposed X-ray film shall be retained for seven years. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be legible and readily available upon the request of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure, the facility staff or any authorized officer, agent, or employee of either, or any other person authorized by law to make such request.(b) Information contained in the health records shall be confidential and shall be disclosed only to authorized persons in accordance with federal, state and local laws. (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the health record shall be authenticated with the date, name, and title of the persons making the entry.(g) All current clinical information pertaining to a patient's stay shall be centralized in the patient's health record. Based on interview and record review, the facility staff failed to maintain accurate and complete health records for two of four residents (Residents 3, 4) reviewed for medication administration. This failure had the potential for resident harm by not presenting a full and accurate record of the resident's status, and potentially missing a change in health. Findings:Resident 3 was admitted to the facility on [DATE], with diagnosis that included: Type 2 diabetes (a disorder of hormone secretion, that causes high blood sugar levels and complications such as kidney failure, circulatory problems, and vision problems); essential hypertension (High blood pressure, which contributes to strokes, heart disease, and kidney disease); and end stage kidney disease (a complication of diabetes and high blood pressure, where kidneys no longer function, leading to a build up of waste products and fluid in the body); and dependence on dialysis (a procedure where blood is artificially filtered by machines that take over the function of the kidneys).Resident 4 was admitted to the facility on [DATE], with diagnosis that included: Type 2 diabetes (a disorder of hormone secretion, that causes high blood sugar levels and complications such as kidney failure, circulatory problems, and vision problems); essential hypertension (High blood pressure, which contributes to strokes, heart disease, and kidney disease); and end stage kidney disease (a complication of diabetes and high blood pressure, where kidneys no longer function, leading to a build up of waste products and fluid in the body); and dependence on dialysis (a procedure where blood is artificially filtered by machines that take over the function of the kidneys).On 9/18/25 at 11:45 A.M. a review of the physician orders, and medication administration records for Residents 3 and 4 was conducted with the Director of Nursing (DON).Resident 3 had a physician order, dated 1/20/25, for Carvedilol (a medication for both high blood pressure or an irregular heart beat), 25mg orally twice a day for high blood pressure with directions to hold (not give) if Resident 3's blood pressure was less than 100 or his heart rate was less than 60. Out of 62 opportunities for this medication to be given, it was omitted 17 times, with reasons documented as other/hold - see progress notes 15 times; in hospital three times; and vitals outside of parameter one time. For the Vitals outside of parameters, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055298 If continuation sheet Page 3 of 4 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 09/18/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there is no documentation of Resident 3's blood pressure or heart rate.Resident 4 had medication orders including: Isosorbide Mononitrate ER 60mg (a blood pressure medication) give once daily for hypertension, hold if blood pressure less than 100 or heart rate (beats per minute) less than 60. Out of 31 opportunities, the record is blank for August 1, the medication was not given due to Resident 4 refusing three times, and was held as outside of parameters once. The blood pressure and heart rate were not documented on the refusals, only an N/A. The medication was given in error on August 10, 2025 when Resident 4's heart rate was below 60 (58). Resident 4 medication order of Glargine Insulin (a long acting medication used to lower blood sugar), dated 9/4/2024, of 8 units subcutaneously (under the skin) daily had 31 opportunities to be given in August 2025. 22 opportunities the insulin was not given, with a notation resident refused and twice the medication was not given for other-see note. On those 22 opportunities, the blood sugar value was not entered, with an N/A (not applicable) entered instead. Resident 4's medication order for Lispro insulin, dated 9/4/24 ( a short acting medication to lower blood sugars) was ordered according to a sliding scale (give a larger dose for a higher blood sugar) at 9 PM. Out of 31 opportunities, one date (August 8) is blank, the medication was documented as given once, on August 1. The blood sugar is listed as 214, and there is no space to document how many units of insulin were given. The remaining 28 days the documention reflects Resident 4 refused the insulin, and there is no record of what the blood sugar was at the time.The DON was interviewed on 9/18/25 at 12:40 P.M. The DON stated it is expected that all residents get their medications as ordered. The DON stated the record should be complete, when the resident is in the facility, of what the vital signs were that caused the medication to be held, so it is entered into the record and trends can be recognized. The DON also stated it is expected that the physician is notified of any missed or refused medications. Event ID: Facility ID: 055298 If continuation sheet Page 4 of 4