Home / California / Fallbrook
325 Potter Street, Fallbrook, CA 92028 · San Diego County · (760) 728-2330
93 certified beds, about 81 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1977
CMS Care Compare ratings, data as of September 1, 2026 · CCN 055298 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 1, 2025, inspectors cited 5 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 20 health citations since September 2019 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.84 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.31 of those hours.
40.9% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to Progressive Health Care Centers, an affiliated group of 5 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 20 health citations on file.
Inspectors wrote22 CCR S 72313S 72313. Nursing Service--Administration of Medications and Treatments(a) Medications and treatments shall be administered as follows:(1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order.(2) Medications and treatments shall be administered as prescribed.(3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded.(4) Preparation of doses for more than one scheduled administration time shall not be permitted. Based on interview and record review, the facility failed to ensure 3 of 4 residents reviewed for omitted medication doses, (Residents 1, 3, and 4) and this failure placed the residents at risk of harm due to uncontrolled high blood presure.
Inspectors wrote22 CCR S 72543S 72543. Patients' Health Recordsa) Records shall be permanent, either typewritten or legibly written in ink, be capable of being photocopied and shall be kept on all patients admitted or accepted for care. All health records of discharged patients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until 1 year after the minor has reached the age of 18 years, but in no case less than 7 years. All exposed X-ray film shall be retained for seven years. [...]
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure leftover and opened food items were labeled and dated when placed in the refrigerator. This deficient practice had the potential to affect all residents who received food from the kitchen.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's call light was placed within reach for 1 (Resident #1) of 19 sampled residents.
Inspectors wroteBased on record review and interview, the facility failed to ensure a Level I preadmission screening and resident review (PASARR) was completed prior to admission for 1 (Resident #8) of 5 sampled residents reviewed for PASARR.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's fingernails and toenails were kept cleaned and trimmed for 3 (Residents #1, #23, and #40) of 4 sampled residents reviewed for activities of daily living (ADL).
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's catheter tubing and privacy bag were kept off the floor for 1 (Resident #14) of 3 sampled residents reviewed for urinary catheters.
Inspectors wroteBased on interview and record review, the facility failed to honor a resident ' s preference for their personal physician for one of three residents (Resident 1) when reviewed. This failure ignored the resident ' s right to choose a physician and caused Resident 1 to feel ignored and depressed.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide a registered nurse (RN) on duty 8 consecutive hours per day, seven days per week. This failure had the potential for more advanced assessments and care activities provided by an RN to be unavailable to residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all food items were labeled and dated. In addition, the facility did not ensure that there were no expired food items. This failure had the potential for all residents who eat at the facility to become ill due to increased bacteria growth in the food, and/or have decreased food intake leading to weight loss due to poor food palatability.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident (Resident 1) was free from a physical restraint when a lap tray was used to keep Resident 1 from falling out of the wheelchair. This deficient practice had the potential to increase Resident 1's risk for injury and potentially a further decline in mobility.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide alternative language accommodations for 3 of 18 sampled residents; (Residents 1, 49, and 45), who had been identified to need alternative communication. This deficient practice had the potential to affect Residents (1, 49, and 45) care and accomedations not being met.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident (Resident 12) safely consumed administered medications when medications were found in Resident 12's bedside drawer. This deficient practice had the potential to put the health and safety of all residents at risk.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physicians' order for oxygen therapy was followed for 1 of 18 sampled residents, Resident 10. As a result, Resident 10 did not receive oxygen therapy as ordered.
Inspectors wroteBased on observation, interview, and record review the facility failed to discard a residents' medication from the medication storage room when the resident was discharged from the facility. This had the potential risk for other residents to be given the wrong medication.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices within the facility when: 1. The facility did not ensure a residents oxygen tubing was labeled and dated when last changed. In additon, 2. The facility did not implement a water management system program. This lack of infection control practices had the potential to expose a vulnerable population of residents to harmful organisms.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in accordance with professional standards of food service safety when: 1. Proper food cool down procedures were not followed. 2. Two resident unit refrigerator temperatures were not consistently monitored. Food in one refrigerator was unlabeled and undated, and one refrigerator was not clean. These failures had the potential for bacterial growth in resident's food and placed residents at risk for food borne illness.
Inspectors wroteBased on interview and record review the facility failed to ensure bruising was evaluated and communicated to the wound treatment nurse for monitoring for one of two residents (45) sampled for anticoagulation (blood thinner) medication side effects. This failure had the potential for bruising to increase in size without monitoring and lead to a delay in treatment for Resident 45.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five residents (3) investigated for falls, had an interdisciplinary team (IDT) meeting (to discuss and implement an updated care plan) following a fall. This had the potential to contribute to additional falls with injury for Resident 3, and miscommunication among health care providers.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure LNs followed their policy and procedure for checking the medication label for the expiration date prior to administering for one randomly sampled resident (276). As a result, Resident 276 received two doses of an expired medication.
19 fire safety citations on file: 7 on May 1, 2025, 3 on July 20, 2023, 9 on September 18, 2019.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.84 | 4.52 | 3.86 |
| Registered nurses | 0.31 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.38 | 4.09 | 3.42 |
| Nurse aides | 2.40 | ||
| Licensed practical nurses | 1.13 | ||
| Nursing staff turnover (share who left in a year) | 40.9% | 36.7% | 45.8% |
| Registered nurse turnover | 57.1% | 38.1% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.26 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.03 on weekdays and 3.38 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 18.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.99 in April to June 2025 to 3.84 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.84 | 0.31 | 4.03 | 3.38 | 18.9% | 0 of 90 | 81 |
| Oct to Dec 2025 | 3.69 | 0.31 | 3.83 | 3.34 | 14.3% | 0 of 92 | 75 |
| Jul to Sep 2025 | 3.63 | 0.38 | 3.85 | 3.07 | 3.3% | 0 of 92 | 77 |
| Apr to Jun 2025 | 3.99 | 0.30 | 4.17 | 3.53 | 3.7% | 1 of 91 | 73 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Trains nurse aides: this home runs a state-approved CNA program for its own hires (state list: CDPH Facility Based Nurse Assistant Training Programs, as of February 13, 2026). A nursing home cannot charge aides it employs, or has offered a job, for state-approved training (42 CFR 483.152(c)). See Fallbrook Skilled Nursing CNA training on CareerFunded, our sister site for career training.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.7 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.2 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.1 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.2 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.4 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 11.9 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.0 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 7.9 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.2 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 6.8 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.0 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Fallbrook Skilled Nursing's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (59.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
59.6% this home
No different from the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 78 eligible stays.
10.4% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 88 eligible stays.
6.7% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 49 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 16 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 40 residents counted.
0.0% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 40 residents counted.
95.0% this home
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 20 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: FALLBROOK HEALTHCARE CENTER OPERATING COMPANY LLC. CMS links this home to Progressive Health Care Centers, a group of 5 nursing homes averaging 3.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Goings Family Trust Dated February 18, 2005 | 5% or greater direct ownership interest | Organization | 33% | 01/23/2015 |
| Helen Louise Larson Revocable Trust Created Under That Certain Declara | 5% or greater direct ownership interest | Organization | 8% | 01/23/2015 |
| The Herman J Tanske Trust Dated May 28, 1987, As Amended | 5% or greater direct ownership interest | Organization | 17% | 01/23/2015 |
| The Larson Family Trust of 2010 As Amended | 5% or greater direct ownership interest | Organization | 8% | 01/23/2015 |
| Victor Avila Family Trust Dated January 26, 1990 | 5% or greater direct ownership interest | Organization | 33% | 01/23/2015 |
| Avila, Stephanie | 5% or greater indirect ownership interest | Individual | 17% | 01/23/2015 |
| Avila, Victor | 5% or greater indirect ownership interest | Individual | 17% | 01/23/2015 |
| Goings, Verna | 5% or greater indirect ownership interest | Individual | 17% | 01/23/2015 |
| Larson, Maria | 5% or greater indirect ownership interest | Individual | 8% | 01/23/2015 |
| McDonald, Jason | W-2 managing employee | Individual | 07/20/2015 | |
| Pisco, Mary Jean | W-2 managing employee | Individual | 07/20/2015 | |
| Goings, Gregory | Corporate officer | Individual | 01/23/2015 | |
| Kilian, James | Corporate officer | Individual | 01/23/2015 | |
| Goings & Goings Inc | Operational/managerial control | Organization | 01/23/2015 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.