Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Commons during CMS and state inspections, most recent first.
A resident received double doses of pregabalin and oxycodone due to a documentation error. A nurse administered the medications outside the prescribed window and failed to sign them out in the EMAR. A med tech, unaware of the prior administration, gave the resident their bedtime medications, leading to the error. The resident was evaluated the next day, showing tachycardia but was otherwise stable.
A resident in an LTC facility potentially received double doses of pregabalin and oxycodone due to a documentation error. The medications were signed out by a nurse who left the facility early, and the EMAR was not updated. The medication technician also administered the medications, leading to concerns about double dosing. The facility's policy for medication administration documentation was not followed.
The facility failed to ensure dignified feeding assistance for residents. A CNA was observed standing over a resident without engaging in conversation during feeding. Another instance involved two CNAs standing over residents while assisting with feeding, confirmed by the Unit Manager.
The facility failed to inform and provide written information about the right to formulate an advance directive for four residents. Surveyors found that the clinical records of these residents lacked documentation of advance directives and evidence that they were informed of their rights. Forms present in the records were either unsigned, blank, or incomplete, indicating a lapse in the facility's responsibility to ensure residents were aware of their rights regarding advance directives.
The facility failed to ensure comprehensive interdisciplinary team (IDT) participation in care planning for multiple residents. Meetings often lacked essential team members such as the attending physician, registered nurse, and CNA, and did not consistently involve the resident or their representative. This deficiency was noted across several residents, with meetings frequently attended only by a registered nurse and nutrition services, or sometimes just one of these members, indicating a systemic issue in the care planning process.
The facility failed to maintain a sanitary environment for respiratory care, as observed in four residents whose oxygen and nebulizer tubing were unlabeled and undated, contrary to facility policy. The clinical records lacked documentation of weekly tubing changes, and observations showed improper storage of respiratory equipment. These deficiencies were confirmed by an LPN and the Director of Clinical Services.
The facility did not maintain proper records for controlled drugs, failing to conduct daily counts as required by policy. The Omnicell cabinet's controlled substances were not consistently counted by two licensed nurses, with numerous days missing counts over several months. This issue was identified during an observation and discussed with the Director of Clinical Services.
The facility failed to ensure proper temperature monitoring for biologicals in two refrigerators on Unit A and a vaccine refrigerator in the Infection Control office. The facility's policy requires monitoring twice daily, but logs showed only once daily monitoring with several missing entries from January to August 2024. The Director of Clinical Services confirmed the lack of consistent monitoring.
The facility failed to maintain sanitary conditions in food storage and preparation areas. Undated and unlabeled desserts and breakfast items were found, and kitchenettes had dirty appliances with incomplete temperature logs. The dish machine's temperature log was also incomplete after repairs, with bleach added without recording parts per million.
The facility's QAA committee meetings lacked attendance from required leadership figures, such as the administrator or owner, as confirmed by attendance records and the DON.
A facility failed to refer a resident with bipolar disorder for a PASRR Level II evaluation after their stay extended beyond the expected short-term period. Initially admitted for short-term convalescence, the resident's stay became long-term, but the necessary referral to the state authority was not made. This oversight was confirmed by the Director of Clinical Services.
A facility failed to develop a discharge summary with a recapitulation of a resident's stay. The resident was admitted for skilled services and later discharged to the community. The clinical record lacked evidence of the required documentation, as confirmed by the Director of Clinical Services during an interview.
A facility failed to follow physician's orders for a resident with Congestive Heart Failure, who was to be weighed weekly. The resident's clinical record lacked evidence of weighing on several specified dates. This deficiency was confirmed in an interview with the DON.
A facility failed to provide trauma-informed care for a resident with PTSD and a history of childhood sexual abuse. Despite the resident's clinical record indicating trauma history, the facility did not identify specific PTSD triggers or events that might cause re-traumatization. The care plan only noted the resident's preference for female caregivers, lacking further trauma-specific interventions. The Director of Clinical Services confirmed the absence of a comprehensive care plan addressing the resident's trauma history.
A resident with Down Syndrome and dementia was physically abused by a CNA during a 1:1 care session. The resident, who became agitated, grabbed the CNA's arm, prompting the CNA to slap the resident's arm and verbally retaliate. This incident was witnessed by another CNA, highlighting a failure to follow the facility's policy and the resident's care plan, which emphasized non-violent interventions for managing agitation.
The facility did not post the most recent survey results in an accessible location for residents and their families. A surveyor found the book meant to contain these results empty, and the Director of Clinical Services was unaware of the results' whereabouts or how long they had been missing.
The facility failed to provide the required CMS-10123-NOMNC and CMS-10055-SNF ABN forms to residents whose Medicare Part A Skilled services were discontinued. Two residents who remained in the facility after their benefits ended did not receive the necessary forms, and another resident discharged to home did not receive the CMS-10123-NOMNC form. This deficiency was identified during a surveyor's review and discussed with the DON.
The facility failed to provide written transfer or discharge notices to residents or their legal representatives for facility-initiated transfers to acute care facilities. Interviews with staff confirmed the absence of such documentation, and the DON was unaware of the requirement.
The facility failed to issue written bed hold notices to residents or their representatives upon transfer to a hospital. This deficiency was identified for five residents, with clinical records lacking evidence of such notices. The DON confirmed the absence of documentation during a survey.
Resident Receives Double Dose of Medications Due to Documentation Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when controlled medications were administered in excess of prescribed doses. On the evening of February 12, 2025, a resident received double doses of pregabalin 75 mg and oxycodone 10 mg. These medications were signed out of the narcotic/control book by a nurse who had left the facility earlier in the shift, and they were not signed out in the electronic medication administration record (EMAR). A medication technician, unaware that the medications had already been administered, gave the resident their bedtime medications, leading to the double dosing. The resident's clinical record indicated that the physician had ordered pregabalin 75 mg to be taken twice daily and oxycodone 10 mg three times daily. The error was discovered when the resident's provider was notified the following day, and the resident was evaluated for the medication error. The resident exhibited tachycardia but was otherwise stable. The facility's policy required documentation of controlled substances, which was not followed, as the nurse did not sign off the medications in the EMAR due to administering them outside the prescribed window. This oversight resulted in the resident receiving additional doses of the medications.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for medication errors. On a specific date, a surveyor noted a medication error report indicating that a resident had potentially received double doses of two medications, pregabalin and oxycodone. The medications were signed out of the narcotic/control book by a nurse who had left the facility earlier in the shift, and they were not signed out in the electronic medication administration record (EMAR). The medication technician reported that the nurse had administered the medications before leaving, but the technician also administered the bedtime medications, leading to concerns about double dosing. The resident's clinical record showed that the medications were prescribed to be administered twice and three times daily, respectively. However, discrepancies were found in the documentation, with the controlled medication book showing the medications signed out by both the nurse and the medication technician. The Nurse Manager confirmed that the nurse did not sign out the administration of the controlled medications in the EMAR, which was against the facility's policy. The Director of Clinical Services also confirmed the nurse's failure to follow the policy for medication administration documentation.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that residents requiring feeding assistance were aided in a dignified manner during dining observations. On August 19, 2024, a surveyor observed a Certified Nursing Assistant (CNA) standing over a resident while feeding them in the C-Unit dining room, without engaging in any conversation. This lack of interaction was confirmed with the CNA and the Director of Nursing. Additionally, on August 20, 2024, another surveyor observed two CNAs standing over residents while assisting with feeding, one in the Unit C dining room and another in the hallway at the nurse's station. These observations were confirmed with the Unit Manager.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide written information concerning the right to formulate an advance directive for four residents. During a survey, it was found that Resident #62's clinical record lacked an advance directive and documentation indicating that the resident was informed about their right to formulate one. Although an Advance Care Planning Tracking form was present, it was unsigned and mostly blank, except for the selection of Full Code. Similarly, Resident #65's record also lacked an advance directive and documentation of being informed about their rights. The form in their record was signed by a representative, but the section for the date of discussion was marked as none, with the rest of the form blank except for a Do Not Resuscitate (DNR) selection. Additionally, Resident #40's clinical record did not contain an advance directive or documentation of being informed about the right to formulate one. The Director of Nursing was unable to locate the necessary documentation for these residents. Furthermore, Resident #21's record also lacked documentation of an advanced directive discussion. After a thorough search, the charge nurse confirmed the absence of such documentation. These findings indicate a failure by the facility to ensure residents were informed and provided with the necessary information to formulate advance directives.
Inadequate Interdisciplinary Team Participation in Care Planning
Penalty
Summary
The facility failed to adequately review and revise care plans by an interdisciplinary team (IDT) for 16 out of 29 residents whose care plans were reviewed. The IDT meetings often lacked the presence of essential team members such as the attending physician, registered nurse, and certified nursing assistant responsible for the resident. Additionally, there was a lack of participation from nutrition services and, to the extent possible, the resident or their representative. This deficiency was noted across multiple residents, with meetings often attended only by a registered nurse and nutrition services, or sometimes just one of these members. For Resident #9, IDT meetings were held with limited attendance, often missing key team members. Similarly, Resident #13's records showed IDT meetings with only dietary and nursing staff present, and no documentation of resident or family participation. Resident #18's meetings also lacked comprehensive team attendance, with some meetings attended only by a registered nurse. This pattern of insufficient IDT participation was consistent across other residents, such as Resident #30, who had meetings with only a registered nurse and nutrition services, and Resident #31, who was unsure of their invitation to care plan meetings. Interviews with residents, such as Resident #31 and Resident #71, revealed that they were not aware of being invited to participate in their care plan meetings. The records for Resident #40, Resident #54, and others showed similar deficiencies, with meetings often attended by only one or two team members, lacking the full interdisciplinary approach required. This lack of comprehensive IDT involvement and resident participation in care planning was a consistent issue across the reviewed cases, indicating a systemic problem in the facility's care planning process.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, as evidenced by observations and record reviews for four residents. The facility's policy requires that nasal cannulas and nebulizer parts be changed weekly, labeled with the date and staff initials, and documented in the Treatment Administration Record (TAR). However, observations revealed that the oxygen and nebulizer tubing for Residents #30, #60, #93, and #70 were unlabeled and undated. Additionally, the clinical records lacked documentation of weekly tubing changes for these residents. Specific observations included Resident #30's oxygen nasal cannula tubing being unlabeled and undated, with the oxygen tubing connected to a CPAP machine resting on the floor. Resident #60's nebulizer tubing was found unlabeled and undated, with the mouthpiece hanging down the backside of the bedside dresser. Resident #93's nebulizer tubing was also unlabeled and undated, with the mask stored among personal belongings. Resident #70's oxygen tubing was undated, and the resident mentioned infrequent use. These deficiencies were confirmed through interviews with the LPN and the Director of Clinical Services, who acknowledged the lack of proper labeling and documentation.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to ensure that controlled drug records were maintained in order and that an account of all controlled drugs was kept to enable reconciliation. Specifically, the facility did not adhere to its policy requiring controlled medications in the Omnicell automated medication dispensing cabinet to be counted at least once daily by two licensed nurses. The accountability log sheet was not consistently signed off as complete. A review of the Daily Omnicell Controlled Substance Cycle Count logs from January 2024 through August 21, 2024, revealed numerous instances of missing daily counts. For example, in January 2024, counts were missing for 9 out of 31 days, and in June 2024, counts were missing for 22 out of 30 days. This deficiency was observed during a visit to the Unit A medication storage room and was discussed with the Director of Clinical Services.
Inadequate Temperature Monitoring of Biologicals
Penalty
Summary
The facility failed to ensure that biologicals were stored at appropriate temperatures in two observed refrigerators on Unit A. The facility's policy, revised on August 24, requires that medications and biologicals be stored at temperatures between 36 to 46 degrees Fahrenheit. During an observation on August 21, the Registered Nurse Manager acknowledged that the temperatures of the refrigerators, which contained insulin, Ozempic, and Tuberculin Purified Protein, should be monitored once or twice daily. However, the temperature logs from January to August 2024 showed that temperatures were only being monitored once daily, with several days missing temperature recordings each month. Additionally, the vaccine refrigerator in the Infection Control office was found to have inadequate temperature monitoring. This refrigerator contained influenza and pneumococcal vaccines. The temperature logs for July and August 2024 indicated that temperatures were monitored only once daily for several days each month. The Director of Clinical Services confirmed the lack of consistent temperature monitoring during the surveyor's observation.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas during observations. On August 19, 2024, undated and unlabeled desserts were found in the reach-in refrigerator, and undated packages of cheese and French toast were observed on a breakfast cart. On August 21, 2024, the Unit A kitchenette's freezer and refrigerator were found to be dirty, although items were labeled with resident names and dates. The Unit B kitchenette had a dirty refrigerator and lacked temperature log documentation for several days in July and August 2024. Additionally, the dish machine's temperature log was incomplete from June 7 to July 9, 2024, after the machine required repairs and the facility was instructed to add bleach without recording the parts per million. These issues were confirmed with the person in charge of the Dietary Department and the Food Service Consultant.
QAA Committee Lacks Required Leadership Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the required members. Specifically, the signed attendance lists for QAA meetings held on June 11, 2024, and July 2, 2024, revealed that the administrator, owner, board member, or another individual in a leadership role did not attend either meeting. During an interview on August 22, 2024, at 9:15 a.m., the Director of Nursing (DON) confirmed that the QAA committee meets weekly, but the Administrator or other leadership figures do not attend these meetings.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis, whose stay extended beyond the expected 30 days, was referred to the appropriate state-designated authority for a PASRR Level II evaluation and determination. The resident was admitted with a diagnosis of bipolar disorder and initially had a PASRR Level I determination that did not require further evaluation due to the expectation of a short-term convalescence admission. However, the resident was not discharged after a short stay and continued to reside in the facility, assessed as needing nursing facility level of care. The clinical record lacked evidence of a referral for a PASRR Level II evaluation after the resident's stay changed from short-term to long-term. This deficiency was confirmed by the Director of Clinical Services during an interview.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to develop a discharge summary that included a recapitulation of the resident's stay for a resident reviewed for discharge. The resident was admitted to the facility for skilled services and was later discharged to the community. Upon review of the clinical record, there was no evidence that a recapitulation of the resident's stay was completed at the time of discharge. This deficiency was confirmed during an interview with the Director of Clinical Services, who was unable to find the necessary documentation in the resident's clinical record.
Failure to Follow Physician's Orders for Resident Weighing
Penalty
Summary
The facility failed to follow physician's orders for a resident with Congestive Heart Failure, who was supposed to be weighed weekly on Tuesdays and Thursdays. The Physician Order Summary sheet dated 4/9/24 specified this requirement. However, there was no evidence in the resident's clinical record that the resident was weighed on several specified dates: 4/18/24, 5/23/24, 6/6/24, 6/11/24, 7/11/24, 7/18/24, and 7/25/24. This deficiency was confirmed during an interview with the Director of Nursing on 8/21/24 at 3:30 p.m.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a known history of PTSD and childhood sexual abuse. Upon admission, the facility's policy required social services to assess residents for trauma history to ensure appropriate treatment and services. However, despite the resident's clinical record indicating a history of sexual abuse and PTSD, the facility did not identify specific PTSD triggers or events that might cause re-traumatization. The resident had expressed a preference for not having male caregivers, which was noted in the care plan, but no further trauma-specific interventions were documented. During an interview, the Director of Clinical Services confirmed the absence of a comprehensive care plan addressing the resident's trauma history, aside from the preference for female caregivers. The facility's failure to develop and implement a detailed care plan with trauma-specific interventions for the resident represents a deficiency in providing trauma-informed care, as required by their policy.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with a diagnosis of Down Syndrome, Conduct Disorder, Alzheimer's disease, and dementia with behavioral disturbance. The resident was receiving 1:1 care from CNA #4 when the incident occurred. According to the report, the resident became agitated and grabbed CNA #4's arm. In response, CNA #4 slapped the resident's arm and verbally retaliated by saying, "How do you like it?" This action was observed by another CNA, who confirmed the physical abuse and verbal response. The facility's policy states that residents should be free from all forms of abuse, including physical abuse. The care plan for the resident indicated specific interventions to manage agitation, such as guiding the resident away from distress and engaging calmly in conversation. However, these interventions were not followed, leading to the escalation of the situation. The incident was reported to the Division of Licensing and Certification, and the facility's failure to adhere to its own policies and care plan resulted in the deficiency.
Failure to Post Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that is easily accessible to residents, family members, and legal representatives. On August 22, 2024, at 9:05 a.m., a surveyor observed that the book containing the Latest Survey Results in the main lobby was empty. When questioned, the Director of Clinical Services was unaware of the location of the survey results and did not know how long the book had been empty.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Provider Non-Coverage (CMS-10123-NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055-SNF ABN) forms to residents whose Medicare Part A Skilled services were discontinued. Specifically, two residents who remained in the facility after their Medicare Part A benefits ended did not receive the necessary CMS-10123-NOMNC and CMS-10055-SNF ABN forms. Additionally, another resident who was discharged to home did not receive the CMS-10123-NOMNC form. These deficiencies were identified during a surveyor's review of a random sample of residents who had been discharged from Medicare Part A coverage. The surveyor discussed the missing forms with the Director of Nursing, highlighting the facility's failure to ensure residents were informed of their Medicare coverage status and potential liability for services not covered. This oversight affected the residents' ability to understand their appeal rights and financial responsibilities after the discontinuation of Medicare Part A benefits.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to issue a written transfer or discharge notice to residents or their legal representatives for facility-initiated transfers or discharges to an acute care facility. This deficiency was identified for five sampled residents who were transferred or discharged without receiving the required documentation. The clinical records for these residents lacked evidence of a written notice being provided, which is a necessary step in the transfer or discharge process. Interviews with facility staff, including the Director of Nursing (DON) and a registered nurse (RN), confirmed the absence of a written transfer or discharge notice. The DON acknowledged the lack of documentation and was unaware that providing such a notice was necessary. The RN mentioned that while a written notice is not used in this facility, they had experience using it in other facilities. This oversight indicates a systemic issue within the facility's procedures for handling transfers and discharges.
Failure to Issue Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to issue a written bed hold notice to residents or their representatives upon transfer to an acute care hospital. This deficiency was identified for five residents who were transferred to a hospital and subsequently admitted. The clinical records for these residents lacked evidence of a written bed hold notice being issued, which is a requirement to inform residents or their representatives about how long their bed will be held during their absence. Interviews with the Director of Nursing (DON) confirmed the absence of documentation for the issuance of bed hold notices for these residents. The DON was unable to locate any evidence that such notices were provided to the residents, their family members, or legal representatives at the time of transfer. This oversight was noted during a survey, highlighting a consistent failure in the facility's process for handling bed hold notifications.
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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 Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedars Nursing Care Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Seaside Healthcare Llc | 1.8 mi | ★★★★★ | 13 | 0 |
| Barron Center | 2.8 mi | ★★★★★ | 34 | 0 |
| Sedgewood Commons | 3.9 mi | ★★★★★ | 0 | 0 |
| Springbrook Center | 4.5 mi | ★★★★★ | 3 | 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.