Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
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)
| Description | Severity |
|---|---|
| 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
| Name | Title | Context |
|---|---|---|
| Rosemary Camire Knight | Administrator | Administrator confirmed findings during survey and exit interviews |
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