Inspection Reports for Fallbrook Woods

ME, 04103

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Inspection Report Summary

The most recent inspection on October 15, 2024, found the facility in substantial compliance with licensing and infection control regulations and noted no deficiencies. Earlier inspections showed some deficiencies, including issues with medication management, documentation of controlled substances, water temperature exceeding limits, and maintenance of a secured fence. No fines, enforcement actions, or complaint investigations were listed in the available reports. Prior reports did not note any substantiated complaints. The inspection history suggests improvement, with the latest survey showing compliance following earlier cited issues.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

30% better than Maine average
Maine average: 5.7 deficiencies/year

Deficiencies per year

4 3 2 1 0
2024

Census

Latest occupancy rate 84% occupied

Based on a October 2024 inspection.

Census over time

40 45 50 55 60 65 Mar 2024 Oct 2024
Inspection Report Census: 47 Capacity: 56 Deficiencies: 0 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 Annual Inspection Census: 48 Capacity: 56 Deficiencies: 4 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.
Severity Breakdown
Class II: 1 Class III: 1
Deficiencies (4)
DescriptionSeverity
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.Class II
Water temperature in resident areas exceeded 120 degrees Fahrenheit, measuring 122 F at a resident accessible sink.Class III
Facility failed to ensure routine maintenance to a secured area fence which was partially detached and leaning.
Report Facts
Census: 48 Total Capacity: 56 Water Temperature: 122
Employees Mentioned
NameTitleContext
Rosemary Camire KnightAdministratorAdministrator confirmed findings during survey and exit interviews

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