Fallbrook Skilled Nursing

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812May 1, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure leftover and opened food items were labeled and dated when placed in the refrigerator. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: 1. An undated facility policy titled, Leftover Foods indicated, Policy: Leftover foods will be stored and served in a safe manner. Procedure: Leftover foods are those that have been prepared for a meal and not served. 1. Storage of leftovers b. Label and date. […]

• No harm, potential for more than minimal, patternF727Jul 20, 2023

  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. 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. […]

• No harm, potential for more than minimal, patternF812Jul 20, 2023

  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. 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 [DATE] 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. […]

• No harm, potential for more than minimal, patternF584Feb 10, 2023

  Based on observation, interview, and record review, the facility failed to ensure a wall panel thermostat was secured and turned on to a comfortable temperature for three of three Confidential Residents (CR1, CR2, CR3). As a result, CR1, CR2, and CR3 felt cold. Findings: On 1/20/23, the California Department of Public Health (CDPH) received a complaint about the facility not having heat. An unannounced visit was conducted to the facility on 1/21/23. Upon entrance to main lobby, the wall panel thermostat temperature read, 68 degrees Fahrenheit. Along the hallway in the B Hall was an opened wall thermostat with a temperature reading of 68.7 degrees Fahrenheit and the Off warning sign was blinking. […]

• No harm, potential for more than minimal, isolatedF760Sep 18, 2025

  22 CCR S 72313S 72313. Nursing Service--Administration of Medications and Treatments(a) Medications and treatments shall be administered as follows:(1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order.(2) Medications and treatments shall be administered as prescribed.(3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded.(4) Preparation of doses for more than one scheduled administration time shall not be permitted.Based on interview and record review, the facility failed to ensure 3 of 4 residents reviewed for omitted medication doses, (Residents 1, 3, and 4) and this failure placed the residents at risk of… […]