Fallbrook Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Fallbrook Rehabilitation and Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF726Feb 27, 2026

  Based on observation, interview, and record review, the facility failed to ensure nursing staff possessed the appropriate competencies and skill sets necessary to provide safe care for 1 of 3 residents reviewed for nursing services (Resident #1).The facility failed to ensure CNA G implemented safe transfer measures on 02/13/2026 at 4:00 a.m. when she attached the lift sling to the handling strap, instead of the sling attachment loop. Resident #1 experienced a fall and sustained a fractured clavicle during a mechanical lift transfer. […]

• Immediate jeopardy, patternF755Aug 8, 2023

  Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 12 residents (Resident #1) reviewed for pharmaceutical services in that: - The facility failed to administer IV antibiotic as ordered by the physician when Resident #1's insurance did not cover the cost for resident to receive the ordered IV antibiotic therapy (Amphotericin B and Avycaz) to treat unresolved infections for 5 days. -The facility failed to review Resident #1's Physician orders and MAR to ensure that all medications were being administered according to physician's orders. An IJ was identified on 8/4/23. […]

• Immediate jeopardy, patternF686Jul 5, 2023

  Based on interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (CR#9, CR#10, and CR#11) of four residents reviewed for treatment/services of pressure ulcers. 1. Facility failed to fully assess CR #9's wound to establish baseline for treatment and obtain treatment orders. 2. Facility failed to ensure CR#9 received wound care for six (6) days during his admission to the facility on [DATE] through 04/17/2023. 3. Facility failed to provide daily wound care to CR#9, CR#10, and CR#11 having multiple days of missed wound care, resulting in CR#11's wound deterioration. An Immediate Jeopardy (IJ) was identified on 06/09/2023. The IJ template was provided to the facility on [DATE] at 12:58 p.m. […]

• Immediate jeopardy, patternF695Feb 16, 2022

  Based on record review and interview, the facility failed to ensure residents received respiratory treatment and care in accordance with professional standards of practice for 2 of 15 residents ( CR#1 and CR #2) reviewed for respiratory, [CONDITION(S)] care and suctioning as evidenced by: The facility failed to ensure that the ventilator circuit for CR#1's ventilator, remained intact and connected. The facility failed to ensure CR #2's oxygen saturation rates were monitored during ventilator checks. These failures placed facility residents who are dependent on ventilators at risk of hypoxemia, hospitalization , and death. An Immediate Jeopardy (IJ) was identified on [DATE]. […]

• Immediate jeopardy, patternF698Feb 16, 2022

  Based on record review and interview, the facility failed to ensure residents who require [CONDITION(S)] services, receive services consistent with professional standards of practice, the person-centered care plan and the resident's goals and preferences for 1 of 3 (CR #3) residents, reviewed for [CONDITION(S)]. The facility failed to ensure that CR #3 was dialyzed 3 times per week as ordered by her physician. The facility failed to consult the physician when CR #3 refused [CONDITION(S)] on [DATE]. […]