Fallbrook Commons

In the surveyor’s words

From the most serious findings on record at Fallbrook Commons, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 11, 2022

  Based on clinical record review, review of the facility's transport training checklist, and interviews, a facility wheelchair van driver failed to follow the wheelchair unloading procedure, this failure resulted in a resident falling off the back of the wheelchair van sustaining a laceration to the right side of his/ her head that required four staples, and sustained a non-displaced fracture of superior sternum, for 1 of 3 residents reviewed for falls. (#2). Finding: Resident #2 was admitted to the facility in May of 2022, for continued rehabilitation and treatment of [CONDITION(S)] ([CONDITION(S)]) with ongoing renal [CONDITION(S)], failure to thrive at home, and for transportation to [CONDITION(S)]. He/She has limited mobility and utilizes a wheelchair. […]

• No harm, potential for more than minimal, patternF689Jun 30, 2026

  Based on observations, interviews, record reviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the residents' environment was free of accident hazards relating to the storage of chemicals being properly secured for 2 of 22 resident rooms (321, 322) on 1 of 3 units ([NAME]). In addition, the facility failed to provide adequate supervision and complete an assessment of resident capabilities and deficits to determine resident safety for 2 of 2 residents reviewed for smoking (R1, R2). Findings: 1.On 6/30/26 at 9:30 a.m., a surveyor observed resident room [ROOM NUMBER] on the [NAME] unit, and noted on the nightstand for bed 2, were: 2 cans of Wizard Double Action 2 in 1 Air Freshener, and 4 cans of Power Stick body spray. […]

• No harm, potential for more than minimal, patternF550Aug 22, 2024

  Based on observations and interviews, the facility failed to ensure that residents who required feeding assistance were aided with feeding in a dignified manner for 2 of 3 dining observations. (#42) Findings: 1. On 8/19/24 between 12:27 p. m. and 12:34 p.m., a surveyor observed the lunch meal service in the C - Unit dining room. A surveyor observed Certified Nursing Assistant #3 (CNA#3) standing over Resident #42 while feeding him/her. In addition, the CNA did not engage in any conversation with the resident while feeding him/her. In an interview, a surveyor confirmed the above findings with CNA #3 on 8/19/24 at 12:34 p.m., and also confirmed the above findings on 8/19/24 at 1:45 p.m. with the Director of Nursing (DON). 44049 2. On 8/20/24 at 8:15 a.m. […]

• No harm, potential for more than minimal, patternF578Aug 22, 2024

  Based on record review, and interviews, the facility failed to inform and provide written information concerning the right to formulate an advance directive for 4 of 16 residents reviewed for advanced directives. ( #62, #65, #40, #21) Findings: 1. On 8/20/24 at 9:22 a.m. a surveyor reviewed Resident #62's clinical record and was unable to locate an advance directive. Also, documentation was not found that the resident was informed and provided information they had the right to formulate an advance directive. An Advance Care Planning Tracking form was located in Resident #62's clinical record but the document was unsigned and blank other than Full Code being selected. On 8/20/24 at 9:34 a.m. a surveyor reviewed Resident #65's clinical record and was unable to locate an advance directive. […]

• No harm, potential for more than minimal, patternF657Aug 22, 2024

  Based on interviews and record review the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included but is not limited to, the attending physician, a registered nurse and Certified Nurses Aid (CNA) with responsibility for the resident, a member of nutrition services and to the extent possible, include the participation of the resident and/or resident's representative, after each Minimum Data Set (MDS) assessment for 16 of 29 residents whose care plans were reviewed (#9, #13, #18, #30, #31, #40, #54, #55, #62, #65, #67, #71, #75 #78, #88, #93 and #95). Findings: 1. […]