Resident 1 takes Metoprolol, a heart medication prescribed at 667mg twice daily at 7 a.m., 1 p.m., and 5 p.m. Out of 93 scheduled doses in August 2025, he missed 12 because he was at dialysis during medication time.
Licensed nurse LN 1 told inspectors on September 18 that he gives medications to "fully oriented residents" to take with them to dialysis appointments. But not Resident 1.
"He does not feel he would remember to do it," LN 1 said.
The nurse admitted he never notified the doctor about the missed doses. He never told the charge nurse either, so they could alert the physician. LN 1 acknowledged Resident 1 "could have problems, like increased signs of high blood pressure, for missing a dose."
Three other dialysis patients experienced similar medication gaps that same month.
Resident 3 goes to dialysis Tuesdays, Thursdays, and Saturdays from 1:30 p.m. to 6:45 p.m. He takes Hydralazine for high blood pressure at 9 a.m. and 5 p.m. daily. In August, he missed 24 out of 62 scheduled doses — 15 times at 5 p.m. and eight times at 9 a.m.
On six separate days in August, Resident 3 received none of his blood pressure medication. Records show he was marked as receiving a dose on August 23, but the medication was actually marked "NA" for not available.
The same resident takes Carvedilol twice daily for high blood pressure and irregular heartbeat, with instructions to withhold the drug if his blood pressure drops below 100 or heart rate falls below 60. He missed 17 out of 62 doses in August.
Resident 4 also attends dialysis three times weekly, picked up at 1 p.m. with no listed return time. His medication record for Isosorbide Mononitrate, prescribed once daily for hypertension, shows multiple problems in August.
The record is completely blank for August 1. He refused the medication three times and it was properly held once when his vital signs fell outside safe parameters.
But on August 10, staff gave him the medication anyway when his heart rate measured just 58 beats per minute — below the 60 threshold that should have triggered a hold.
The facility's own policies, dating to April 2007, require providing residents with necessary medications when they leave temporarily. The policy states residents away during medication passes "will be given scheduled and essential PRN medication(s) to take with them."
Director of Nursing told inspectors on September 18 that "all residents get their medications as ordered." She acknowledged the facility needed to notify physicians about missed medications and clarify whether to adjust administration times or send medications with residents to dialysis.
The missed doses affected critical cardiovascular medications. Metoprolol treats high blood pressure and prevents heart attacks. Hydralazine dilates blood vessels to reduce blood pressure. Carvedilol manages both blood pressure and heart rhythm disorders.
Sudden discontinuation of these medications can trigger rebound hypertension, where blood pressure spikes dangerously high. The phenomenon poses particular risks for dialysis patients, whose cardiovascular systems already face significant stress from the treatment process.
LN 1's selective approach to medication management — sending pills with some residents but not others based on his assessment of their memory — contradicted established facility policy. His failure to communicate missed doses to physicians left doctors unaware their patients were receiving incomplete treatment.
The inspection found no evidence that physicians had ordered temporary holds on the missed medications. Progress notes cited reasons like "hold - see progress notes" and "other - see progress notes," but the actual notes referenced hospitalizations or dialysis appointments, not medical decisions to withhold treatment.
For Resident 4, the August 10 medication error represented the opposite problem — receiving a dangerous drug despite clear parameters to withhold it. Staff gave him blood pressure medication when his heart rate had already dropped to 58, two beats below the safety threshold.
The facility received a minimal harm citation affecting few residents. But the pattern revealed systematic failures in medication management for the facility's most vulnerable patients — those requiring life-sustaining dialysis treatment three times weekly.
None of the affected residents' physicians were notified about the medication gaps during August. The discovery came only during the September complaint investigation, meaning doctors spent weeks unaware their cardiovascular patients were missing critical treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fallbrook Skilled Nursing from 2025-09-18 including all violations, facility responses, and corrective action plans.