20 Reports
Inspection Report — Jun 30, 2026
Complaint Investigation
Date: Jun 30, 2026
Visit Reason
An unannounced on-site visit was completed for complaint investigation #3042751 due to concerns about safety hazards and supervision related to smoking and chemical storage.
Findings
The facility failed to ensure a safe environment free of accident hazards, including improper storage of chemicals and inadequate supervision for residents who smoke. Additionally, the facility did not develop and implement a comprehensive care plan addressing smoking safety for residents.
Deficiencies (3)
F0689: The facility failed to ensure the resident environment was free of accident hazards, including improper storage of chemicals and inadequate supervision for residents who smoke.
F0656: The facility failed to develop and implement a comprehensive care plan for smoking safety for 1 of 2 residents reviewed.
F0921: The facility failed to maintain a clean and sanitary environment in 2 of 22 resident rooms observed, including odors, unmade beds, clutter, and damaged furniture.
Report Facts
: 3042751
: 22
: 3
Inspection Report — May 28, 2025
Complaint Investigation
Date: May 28, 2025
Visit Reason
An unannounced on-site visit was conducted for the purpose of investigating complaint #ME00051613.
Findings
Fallbrook Commons was determined to be in substantial compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.
Inspection Report — Apr 23, 2025
Follow-Up
Date: Apr 23, 2025
Visit Reason
Follow-up survey conducted to assess correction of deficiencies cited during complaint survey #ME00050598 dated 3/4/25.
Findings
Fallbrook Commons was found to be in compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
: ME00050598
: Mar 4, 2025
Inspection Report — Apr 23, 2025
Complaint Investigation
Date: Apr 23, 2025
Visit Reason
Investigation of complaint #ME00051219.
Findings
Fallbrook Commons was found to be in substantial compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities.
Inspection Report — Mar 31, 2025
Complaint Investigation
Date: Mar 31, 2025
Visit Reason
Investigation of complaints #ME00049101, #ME00050266, #ME00051013, and #ME00051018 to determine compliance with Medicare and Medicaid Federal Conditions of Participation requirements for nursing homes.
Findings
No regulatory deficiencies were identified as a result of the 3/31/25 investigation; the facility was found to be in compliance.
Report Facts
: ME00049101
: ME00050266
: ME00051013
: ME00051018
Inspection Report — Nov 7, 2024
Re-Inspection
Date: Nov 7, 2024
Visit Reason
This is a Federal Recertification Survey Revisit conducted to assess compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition.
Findings
The facility failed to ensure that fire drills were held at expected and unexpected times under varying conditions, at least quarterly on each shift as required by NFPA 101, Life Safety Code, 2012 Edition, Section 19.7.1.6.
Deficiencies (1)
K712: The facility failed to provide documentation of fire drills performed after the 08/20/2024 federal inspection. The administrator stated no fire drills had been performed since moving into the new facility on 09/20/2024.
Report Facts
: Nov 7, 2024
: Aug 20, 2024
: Sep 20, 2024
: 15:30-16:30
Inspection Report — Nov 7, 2024
Plan of Correction
Date: Nov 7, 2024
Visit Reason
This document is the facility's plan of correction for the Federal Recertification Survey conducted on 11/07/2024.
Findings
This plan of correction addresses the deficiency related to Fire Drills (K712) cited in the survey of 11/07/2024.
Report Facts
: 12
Inspection Report — Oct 29, 2024
Follow-Up
Date: Oct 29, 2024
Visit Reason
Follow-up on deficiencies cited during the Annual Recertification survey conducted 8/19/24 - 8/22/24.
Findings
Fallbrook Commons was determined to be in compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities. No deficiencies were cited during this follow-up survey.
Inspection Report — Oct 15, 2024
Date: Oct 15, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Fallbrook Woods, a Level IV PNMI Residential Care Facility, related to regulatory licensing and infection control compliance.
Findings
Fallbrook Woods is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, including infection control.
Inspection Report — Mar 27, 2024
Annual Inspection
Date: Mar 27, 2024
Visit Reason
The inspection was a biennial survey to assess compliance with regulations governing the licensing and functioning of Level IV PNMI Residential Care Facilities.
Findings
The facility was found not in substantial compliance due to deficiencies in medication management, including failure to have required medications on hand, failure to document Schedule II controlled substances weekly, water temperature exceeding allowed limits, and lack of routine maintenance to a secured area fence.
Deficiencies (4)
Facility failed to follow a medication order; Morphine and Lorazepam were not available on the day of the survey despite orders requiring them to be on hand.
Facility failed to document weekly counts of Schedule II controlled substances in the Schedule II Bound Book as required.
Water temperature in resident areas exceeded 120 degrees Fahrenheit, measuring 122 F at a resident accessible sink.
Facility failed to ensure routine maintenance to a secured area fence which was partially detached and leaning.
Report Facts
Water Temperature: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosemary Camire Knight | Administrator | Administrator confirmed findings during survey and exit interviews |
Inspection Report — Mar 26, 2024
Complaint Investigation
Date: Mar 26, 2024
Visit Reason
Investigation of complaints #ME00045524, #ME00045692, and #ME00046277.
Findings
St. Joseph's Rehabilitation and Residence was found to be in compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: #ME00045524
: #ME00045692
: #ME00046277
Inspection Report — Jan 30, 2024
Complaint Investigation
Date: Jan 30, 2024
Visit Reason
An unannounced on-site visit was conducted to investigate complaint #ME00046142.
Findings
St. Joseph's Rehabilitation and Residence was found to be in compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: ME00046142
Inspection Report — Dec 12, 2023
Complaint Investigation
Date: Dec 12, 2023
Visit Reason
An unannounced on-site visit was conducted to investigate facility reported incident #ME00045664.
Findings
St. Joseph's Rehabilitation and Residence was found to be in compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: ME00045664
Document — IHQD22 SOD
Date: IHQD22 SOD
Inspection Report — XA8W11 POC
Plan of Correction
Date: XA8W11 POC
Visit Reason
This document is the facility's plan of correction for the survey conducted on 8/22/2024, addressing multiple deficiencies cited in the survey.
Findings
This plan of correction addresses deficiencies related to resident rights, survey results, advance directives, Medicaid/Medicare coverage, freedom from abuse, transfer/discharge notices, bed hold policy, PASARR screening, care plan timing, discharge summary, quality care, respiratory care, trauma informed care, pharmacy services, drug storage, food procurement, and quality assurance committee.
Report Facts
: 4
: 3
: 2
: 2
: 1
: 5
: 4
: 1
: 16
: 1
: 1
: 4
: 1
: 2
: 2
: 1
: 1
Inspection Report — XA8W21 SOD
Date: XA8W21 SOD
Visit Reason
Federal Recertification Survey of St Joseph's Rehabilitation and Residence.
Findings
The facility was found not in substantial compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition. Multiple deficiencies were identified related to emergency preparedness, means of egress, fire alarm system maintenance, sprinkler system maintenance, fire extinguishers, electrical systems, and oxygen storage.
Deficiencies (14)
E015: The facility failed to maintain provision of subsistence needs for staff and patients in the emergency preparedness plan, including food, water, medical and pharmaceutical supplies, and fuel for the generator.
K211: The facility failed to maintain aisles, passageways, corridors, exit discharges, and exit locations free of obstructions in 3 of 4 resident care wings.
K222: The facility failed to ensure that special locking arrangements for clinical or security needs met all requirements, including automatic unlocking upon activation and rapid removal of occupants.
K321: The facility failed to ensure elevator lobby exit access doors met locking requirements and failed to maintain doors at means of egress to meet NFPA 101 life safety code.
K324: The facility failed to properly install and maintain cooking equipment protection and fire suppression systems in accordance with NFPA standards.
K345: The facility failed to maintain and test the fire alarm system in accordance with NFPA standards, including documentation of testing and sensitivity.
K353: The facility failed to maintain the wet sprinkler system per NFPA 25 standards, including inspection, testing, and maintenance documentation.
K355: The facility failed to ensure portable fire extinguishers were inspected, maintained, and documented in accordance with NFPA 10 standards.
K363: The facility failed to maintain corridor doors to close properly and resist passage of smoke, including issues with door latching and labeling.
K374: The facility failed to maintain cross-corridor smoke barrier doors to close properly and resist passage of smoke.
K712: The facility failed to conduct required fire drills at expected and unexpected times under varying conditions, including documentation of drills.
K918: The facility failed to maintain electrical system inspections and testing, including weekly generator inspections and monthly under load tests.
K919: The facility failed to address electrical equipment deficiencies and include required K-tags and documentation on Form CMS-2567.
K923: The facility failed to maintain multiple patient room outlet connections, missing outlet covers, and proper air conditioning unit connections.
Report Facts
: Aug 20, 2024
: 09:00 AM to 3:00 PM
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