Deficiency Records for Fallbrook Rehabilitation and Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Fallbrook Rehabilitation and Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-08-18 | 2023-08-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-18 | 2023-08-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-18 | 2023-08-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-18 | 2023-08-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-08 | 2023-08-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-05 | 2023-07-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-05 | 2023-07-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-05 | 2023-07-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-05 | 2023-07-06 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-03-15 | 2023-03-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-16 | 2023-01-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-16 | 2023-01-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-01-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-16 | 2023-01-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-16 | 2023-01-16 | N |
| 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. | Health | 2022-12-16 | 2023-01-16 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-16 | 2023-01-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-16 | 2023-01-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-16 | 2023-01-16 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-13 | 2023-01-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-13 | 2023-01-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-13 | 2023-01-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-13 | 2023-01-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-20 | 2022-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-20 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-04 | 2022-09-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-04 | 2022-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-04 | 2022-09-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-04 | 2022-09-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-04 | 2022-09-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-04 | 2022-09-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-04 | 2022-09-16 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-08-04 | 2022-09-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-16 | 2022-03-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-16 | 2022-03-16 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-16 | 2022-03-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-16 | 2022-03-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-18 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-19 | 2021-11-11 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-09-29 | 2021-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-29 | 2021-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-29 | 2021-10-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-29 | 2021-10-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-09-29 | 2021-10-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-29 | 2021-10-25 | N |
| Post nurse staffing information every day. | Health | 2021-09-29 | 2021-10-25 | N |
| 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. | Health | 2021-09-29 | 2021-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-29 | 2021-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-25 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-09-29 | 2021-10-25 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-10-01 | 2021-10-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-03 | 2021-10-25 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-23 | 2021-10-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-03 | 2021-08-26 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-08-03 | 2021-08-26 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-03 | 2021-08-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-03 | 2021-08-26 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-21 | 2021-08-04 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-02 | 2019-06-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-02 | 2019-06-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-02 | 2019-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-02 | 2019-06-16 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-05-02 | 2019-06-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-02 | 2019-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-05-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-05-02 | 2019-05-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-02 | 2019-05-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-02 | 2019-05-31 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-05-02 | 2019-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-02 | 2019-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-05-31 | N |
