Cycle 1
Health 2025-05-01 · Fire 2025-05-01
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fallbrook, CA
Fallbrook Skilled Nursing
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
325 Potter Street, Fallbrook, CA
(760) 728-2330
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Progressive Health Care Centers
Operator or chain grouping
Approved since
1977-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 1 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.12
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,933
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.58
Baseline 21.43% · Performance 20.70% · Measure score 1.58 · Achievement 1.58 · Improvement 1.16
Healthcare-associated infections
3.93
Baseline 6.71% · Performance 6.66% · Measure score 3.93 · Achievement 3.93 · Improvement 0
Total nurse turnover
3.20
Baseline 48.33% · Performance 50.59% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Adjusted total nurse staffing
2.62
Baseline 3.40 hours · Performance 3.82 hours · Measure score 2.62 · Achievement 2.62 · Improvement 1.27
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 7.95% · Lower 95% interval 6.9% |
| Discharge to community | 59.65% |
50.57%
9.1 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 60.26% · Lower 95% interval 50.29% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.02% |
95.27%
2.2 pts worse
|
Numerator 40 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 43 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 4.08% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 18.89% |
8.2%
10.7 pts better
|
Numerator 17 · Denominator 90 |
| Staff flu vaccination coverage | 69.09% |
42%
27.1 pts better
|
Numerator 76 · Denominator 110 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.3
0.2 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.6
1.3 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
1.6%
0.8 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 11.3% |
4.1%
7.2 pts worse
|
5.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.1% · Q3 7.3% · Q4 10.5% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
13.7%
3 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 13.2% · Q3 8.8% · Q4 6.9% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
14.2%
7.6 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 5.0% · Q3 8.9% · Q4 10.0% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.0% |
11.0%
1 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 16.2% · Q3 3.0% · Q4 8.6% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
10.7%
0.6 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 10.2% · Q3 9.4% · Q4 11.3% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.0%
0.1 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.8% · Q3 1.3% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.2%
0.9 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.0% · Q3 0.0% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.4% |
10.9%
3.5 pts worse
|
19.8%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 25.2% · Q3 4.8% · Q4 20.8% · 4Q avg 14.4% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.7%
0.1 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.9% · Q3 1.9% · Q4 5.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.1% |
11.2%
8.9 pts worse
|
12.0%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 20.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 2.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
93.2%
5 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
23.2%
2.2 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 25.7% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-09-18 · Fire 2019-09-18
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-05-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-05-01
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-01
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-28
E · Potential for more than minimal harm
2023-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-08
D · Potential for more than minimal harm
2023-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-08
D · Potential for more than minimal harm
2019-09-18
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-11-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-07
D · Potential for more than minimal harm
2025-09-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-07
F · Potential for more than minimal harm
2025-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-31
D · Potential for more than minimal harm
2024-10-29
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2024-12-04
E · Potential for more than minimal harm
2023-07-20
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-07-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-20
E · Potential for more than minimal harm
2019-09-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-10-18
Penalties and ownership
What sits behind the stars
Ownership
Goings Family Trust Dated February 18, 2005
5% Or Greater Direct Ownership Interest · Organization
Victor Avila Family Trust Dated January 26, 1990
5% Or Greater Direct Ownership Interest · Organization
Avila, Stephanie
5% Or Greater Indirect Ownership Interest · Individual
Avila, Victor
5% Or Greater Indirect Ownership Interest · Individual
Goings, Verna
5% Or Greater Indirect Ownership Interest · Individual
The Herman J Tanske Trust Dated May 28, 1987, As Amended
5% Or Greater Direct Ownership Interest · Organization
Helen Louise Larson Revocable Trust Created Under That Certain Declara
5% Or Greater Direct Ownership Interest · Organization
Larson, Maria
5% Or Greater Indirect Ownership Interest · Individual
The Larson Family Trust Of 2010 As Amended
5% Or Greater Direct Ownership Interest · Organization
Goings & Goings Inc
Operational/Managerial Control · Organization
Goings, Gregory
Corporate Officer · Individual
Kilian, James
Corporate Officer · Individual
Mcdonald, Jason
W-2 Managing Employee · Individual
Pisco, Mary Jean
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Temecula Healthcare Center
Temecula, CA
2-star overall rating with 2-star inspections with $17,765 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Santa Fe Post-Acute
Vista, CA
1-star overall rating with 2-star inspections with $85,943 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
The Springs Health And Rehabilitation Center
Murrieta, CA
3-star overall rating with 3-star inspections with $26,918 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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