Fallbrook Skilled Nursing
325 Potter Street, Fallbrook, CA 92028 · San Diego County · 93 certified beds · avg 81 residents/day · certified since Jul 1, 1977
Part of chain: PROGRESSIVE HEALTH CARE CENTERS (5 facilities, chain avg rating 3.8★)
4/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
4.53
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (20)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Sep 18, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 1, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 1, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 29, 2024 | D · Potential for harm, one-off | The facility did not honor a resident's right to choose their own attending doctor. Residents get to decide which physician oversees their care. · from a complaint |
| Jul 20, 2023 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jul 20, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 18, 2019 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 18, 2019 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 18, 2019 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 18, 2019 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 4 | 0 | E |
| 2023 | 8 | 0 | E |
| 2024 | 1 | 0 | D |
| 2025 | 7 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.53 | 4.31 | 3.95 | top 28% in California; top 22% in the U.S. |
| Registered Nurse hours | 0.37 | 0.61 | 0.69 | bottom 25% in California; bottom 17% in the U.S. |
| Weekend total nurse staffing | 3.98 | 3.90 | 3.50 | top 34% in California; top 23% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.19 | 0.51 | 0.48 | bottom 7% in California; bottom 10% in the U.S. |
| Total nursing staff turnover (%) | 40.9 | 36.7 | 45.8 | bottom 36% in California; top 39% in the U.S. |
| RN turnover (%) | 57.1 | 38.1 | 42.9 | bottom 18% in California; bottom 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.84, RN 0.31, weekend 3.38. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avila, Stephanie | Individual | 5% or Greater Indirect Ownership Interest | 17% | 01/23/2015 |
| Avila, Victor | Individual | 5% or Greater Indirect Ownership Interest | 17% | 01/23/2015 |
| Goings Family Trust Dated February 18, 2005 | Organization | 5% or Greater Direct Ownership Interest | 33% | 01/23/2015 |
| Goings, Verna | Individual | 5% or Greater Indirect Ownership Interest | 17% | 01/23/2015 |
| Helen Louise Larson Revocable Trust Created Under That Certain Declara | Organization | 5% or Greater Direct Ownership Interest | 8% | 01/23/2015 |
| Larson, Maria | Individual | 5% or Greater Indirect Ownership Interest | 8% | 01/23/2015 |
| The Herman J Tanske Trust Dated May 28, 1987, as Amended | Organization | 5% or Greater Direct Ownership Interest | 17% | 01/23/2015 |
| The Larson Family Trust of 2010 as Amended | Organization | 5% or Greater Direct Ownership Interest | 8% | 01/23/2015 |
| Victor Avila Family Trust Dated January 26, 1990 | Organization | 5% or Greater Direct Ownership Interest | 33% | 01/23/2015 |
| Goings & Goings INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/23/2015 |
| Goings, Gregory | Individual | Corporate Officer | NOT APPLICABLE | 01/23/2015 |
| Kilian, James | Individual | Corporate Officer | NOT APPLICABLE | 01/23/2015 |
| McDonald, Jason | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/20/2015 |
| Pisco, Mary Jean | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/20/2015 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member wants to keep or change their doctor, how do you handle that request?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Temecula Healthcare Center | 10.8 mi | Temecula, CA | ★★☆☆☆ | 2/5 | |
| Santa Fe Post-Acute | 10.9 mi | Vista, CA | ★★☆☆☆ | 2/5 | |
| The Springs Health and Rehabilitation Center | 12.1 mi | Murrieta, CA | ★★★★☆ | 4/5 | |
| Vista View Post Acute | 12.5 mi | Vista, CA | ★★★★☆ | 3/5 | |
| Vista Knoll Specialized Care Facility | 13.2 mi | Vista, CA | ★★★★★ | 4/5 | |
| Pacific Villas Post Acute | 13.6 mi | Oceanside, CA | —/5 | ||
| La Paloma Healthcare Center | 13.6 mi | Oceanside, CA | ★★★★★ | 5/5 | |
| Murrieta Health and Rehabilitation Center | 13.7 mi | Murrieta, CA | ★★☆☆☆ | 2/5 | |
| Bayshire Carlsbad | 15.0 mi | Carlsbad, CA | ★★★★☆ | 4/5 | |
| Carlsbad by the Sea | 16.5 mi | Carlsbad, CA | ★★★★★ | 5/5 | |
| Village Square Healthcare Center | 17.3 mi | San Marcos, CA | ★★★★☆ | 4/5 | |
| Meadowbrook Village Christian Retirement Community | 17.7 mi | Escondido, CA | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055298.