Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fallbrook Skilled Nursing during CMS and state inspections, most recent first.
Three residents with complex medical needs, including end stage renal disease and hypertension, did not consistently receive prescribed medications on days they attended dialysis. Missed doses were documented in medication records, often attributed to the residents being out for dialysis, and staff interviews confirmed that medications were not always provided to take with them or rescheduled. Facility policy required providing necessary medications for residents on leave, but this was not consistently implemented, and physicians were not always notified of missed doses.
Staff failed to maintain accurate and complete medication administration records for two residents with complex medical conditions, resulting in missing documentation of vital signs, incomplete records of medication refusals, and unclear insulin administration details. The DON confirmed expectations for complete documentation and physician notification of missed or refused medications.
Surveyors observed that leftover and opened food items, including plates of hamburgers and French fries as well as various snacks and beverages, were stored in facility refrigerators without required labels or dates. Staff interviews confirmed that all food items should be labeled and dated per facility policy, and that nursing staff are responsible for monitoring and removing items as needed.
A resident with a history of traumatic brain injury and intact cognition was repeatedly observed with their call light out of reach, including instances where it was on the floor or on the bed while the resident was in a wheelchair. Staff interviews confirmed the call light should have been accessible, and both the DON and Administrator stated this was the facility's expectation.
A resident with schizophrenia and major depressive disorder was admitted without completion of the required Level I PASARR screening. Medical records and assessments documented the resident's mental health diagnoses, but no evidence of PASARR completion was found. Staff interviews confirmed that the responsible personnel did not ensure the necessary screenings were performed.
Surveyors found that three residents who were dependent on staff for ADLs had long, dirty, or jagged fingernails and, in one case, long and curled toenails. Staff interviews confirmed that nail care was part of their responsibilities, and residents expressed a desire for proper nail hygiene, but the required care was not provided according to facility policy and care plans.
A resident with severe cognitive impairment and an indwelling urinary catheter was repeatedly observed with their catheter tubing and privacy bag lying on the floor, contrary to facility policy. Despite staff presence in the room, the catheter bag was not repositioned, indicating a failure to follow established infection prevention protocols.
A resident with the capacity to make healthcare decisions was denied the right to see her preferred physician, as the facility canceled her appointment and insisted she see the facility's doctor. This decision was made without confirming the resident's wishes or checking insurance coverage for transportation, leading to the resident feeling ignored and depressed.
Failure to Administer Medications as Ordered for Residents on Dialysis
Penalty
Summary
The facility failed to ensure that medications and treatments were administered as ordered for three of four residents reviewed for omitted medication doses. Specifically, residents with diagnoses including end stage renal disease, dependence on dialysis, type 2 diabetes, and essential hypertension did not consistently receive their prescribed medications, particularly on days when they were out of the facility for dialysis. Medication administration records showed multiple missed doses of blood pressure and other essential medications, with documentation often indicating the resident was at dialysis as the reason for omission. In some cases, the medication was not provided to the resident to take with them, and there was no evidence that the physician was notified of the missed doses or that alternative arrangements were made. Interviews with staff revealed that medication administration was not consistently adapted to accommodate residents' dialysis schedules. For example, a nurse stated that he would provide medications to fully oriented residents to take with them, but did not do so for one resident, believing the resident would not remember to take the medication. The nurse also admitted to not notifying the physician or the charge nurse about the missed doses. The Director of Nursing acknowledged that all residents are expected to receive medications as ordered and recognized the need to address the issue, but at the time of the survey, the deficiency persisted. Facility policy required that residents leaving the facility temporarily be provided with necessary medications, but this was not consistently followed. The lack of coordination between medication administration times and residents' dialysis schedules, combined with inadequate communication with physicians regarding missed doses, resulted in multiple missed opportunities for residents to receive essential medications as prescribed.
Incomplete and Inaccurate Medication Administration Records
Penalty
Summary
Facility staff failed to maintain accurate and complete health records for two residents who were reviewed for medication administration. Both residents had complex medical conditions, including Type 2 diabetes, essential hypertension, end stage kidney disease, and dependence on dialysis. The review of physician orders and medication administration records revealed multiple instances where required documentation was missing or incomplete. For one resident, a medication for high blood pressure was omitted 17 times out of 62 opportunities, with the reason for omission often noted as 'other/hold - see progress notes,' but without corresponding documentation of vital signs in at least one instance. For the other resident, medication administration records were incomplete, with blank entries, missing documentation of blood pressure and heart rate during refusals, and an instance where medication was administered despite the resident's heart rate being below the ordered parameter. Additionally, insulin administration records were incomplete, with missing blood sugar values and unclear documentation of the number of units administered. During an interview, the DON confirmed that it is expected for all residents to receive medications as ordered and for records to be complete, including documentation of vital signs when medications are held. The DON also stated that physicians should be notified of any missed or refused medications. The lack of complete and accurate documentation in the residents' health records did not present a full and accurate account of their status and could result in missed changes in health.
Failure to Label and Date Leftover and Opened Food Items in Refrigerators
Penalty
Summary
The facility failed to ensure that leftover and opened food items were properly labeled and dated when stored in refrigerators, as required by facility policy. During an observation of the kitchen's reach-in refrigerator, surveyors found two plates containing a hamburger and French fries, and one plate with pureed hamburger and pureed French fries, none of which were labeled or dated. The Dietary Manager confirmed that these items should have been labeled and dated according to policy. Additionally, the facility's policy for foods brought by family or visitors requires perishable foods to be stored in resealable containers with labels indicating the resident's name, the item, and a use-by date. Further observations in the nourishment refrigerator on one of the stations revealed an empty drink bottle, an opened box of strawberry snack cakes, and an opened bottle of a sports-themed beverage, none of which were labeled or dated. The Dietary Manager stated these items appeared to belong to staff and should not have been in the residents' refrigerator, and also confirmed they should have been labeled and dated. Multiple staff interviews, including with a CNA, LPN, RN, DON, and the Administrator, confirmed that staff were aware of the requirement to label and date all food items placed in the refrigerator and that the responsibility for checking and removing items rested with nursing staff.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within reach, as required by facility policy and staff expectations. Observations revealed that the resident, who had a history of traumatic brain injury and demonstrated intact cognition with a BIMS score of 13, was found in bed with the call light on the floor behind the bed. On a subsequent occasion, the resident was in a wheelchair next to the bed, and the call light was observed on the bed, out of the resident's reach. When asked, the resident indicated they could not reach the call light. Staff interviews confirmed that the call light should have been placed within the resident's reach. A CNA acknowledged placing the call light on the bed and admitted the resident would not be able to access it, subsequently moving it within reach. Both the DON and the Administrator stated their expectation that staff ensure call lights are always accessible to residents. The facility's policy on fall risk reduction also specified that call lights should be within reach.
Failure to Complete Required PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Level I preadmission screening and resident review (PASARR) was completed prior to admission for one resident with diagnoses of schizophrenia and major depressive disorder. The resident's admission record confirmed these mental health diagnoses, and subsequent assessments, including the Minimum Data Set (MDS) and care plan, documented ongoing mental health conditions. Despite these documented diagnoses, there was no evidence in the medical record that a Level I PASARR had been completed. Interviews with the Business Office Manager (BOM), Director of Nursing (DON), and Administrator confirmed that the BOM was responsible for ensuring PASARR completion and that the resident should have received both Level I and Level II screenings due to their mental illness diagnoses.
Failure to Maintain Clean and Trimmed Nails for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADLs) had their fingernails and toenails kept clean and trimmed, as required by facility policy. Observations and interviews revealed that three residents, all with significant medical histories and varying levels of cognitive impairment, had long, dirty, or jagged fingernails and, in one case, long and curled toenails. These residents were documented as requiring staff assistance for personal hygiene and nail care, and their care plans specifically directed staff to check, trim, and clean nails on bath days and as necessary. Staff interviews confirmed that nail care was considered part of ADL provision, and that the residents in question were dependent on staff for this aspect of their care. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that the residents' nails needed attention, with some staff noting that toenail trimming should be referred to a nurse or podiatrist. Despite these acknowledgments, the residents' nails remained untrimmed and uncleaned at the time of surveyor observations. Residents themselves expressed a preference for having their nails kept clean and trimmed, and in one case, a resident reported that no one had ever offered to trim their nails. Facility leadership, including the Director of Nursing and the Administrator, stated that their expectation was for staff to keep residents' nails trimmed and clean, yet this standard was not met for the sampled residents reviewed during the survey.
Failure to Maintain Catheter Tubing and Bag Off the Floor
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter tubing and privacy bag were kept off the floor, as required by facility policy. The policy, revised in September 2014, specifically stated that catheter tubing and drainage bags must not be placed on the floor. Resident #14, who had a history of epilepsy and severe cognitive impairment, was admitted to the facility in November 2012 and had an indwelling urinary catheter. The resident's care plan identified a risk for skin integrity issues related to the use of the catheter. Multiple observations revealed that the resident's catheter tubing and privacy bag were repeatedly found lying on the floor beside the bed. On several occasions, including when a CNA entered the room, the catheter bag remained on the floor and was not repositioned. During an interview, the Administrator confirmed that staff were trained and expected to maintain proper catheter care, but the required standard was not met in this instance.
Failure to Honor Resident's Choice of Physician
Penalty
Summary
The facility failed to honor a resident's preference for their personal physician, which violated the resident's right to choose their attending physician. The resident, who was admitted with diagnoses including recurrent enterocolitis, heart disease, major depressive disorder, and anxiety, had the capacity to make her own healthcare decisions. Despite this, the facility canceled her appointment with her regular doctor, insisting she see the facility's doctor instead. This decision was made without confirming the resident's wishes or checking insurance coverage for transportation to her preferred doctor, leading the resident to feel ignored and depressed. The Director of Social Services (SSD) and the Director of Nurses (DON) were involved in the decision to cancel the appointment. The SSD expressed concern about payment issues between the facility's doctor and the resident's chosen doctor, and assumed the resident wanted both doctors without verifying. The DON acknowledged the resident's right to choose her doctor and mentioned that the facility typically provides transportation to medical appointments, but the facility's bus was broken at the time of the resident's appointment. The facility's policy on resident rights supports the resident's choice of physician, but this was not upheld in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fallbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Temecula Healthcare Center | 10.8 mi | ★★★★★ | 7 | 0 |
| Santa Fe Post-acute | 11 mi | ★★★★★ | 11 | 1 |
| The Springs Health And Rehabilitation Center | 12.1 mi | ★★★★★ | 9 | 0 |
| Vista View Post Acute | 12.5 mi | ★★★★★ | 1 | 0 |
| Vista Knoll Specialized Care Facility | 13.2 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.