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Medicare shows an abuse citation on record. Review the linked inspection sources and ask the facility about corrective action before deciding.
based on 211 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Medicare shows an abuse citation on record. Read the linked source details, ask the administrator what corrective action was taken, and independently verify the facility’s current status before deciding.
Families often praise the facility for its warm, professional admissions process and the compassionate nature of specific staff members like Zoe and Ronda. However, there are serious, recurring allegations regarding neglect, including failure to respond to call lights and inadequate hygiene care. While many find the building clean and the therapy programs effective, the presence of severe reports of patient neglect and medication errors necessitates extreme caution and frequent family oversight.
Quality Themes
Tap a score for detailsStrengths
Concerns
Rating Trends
Tap a year to see what changed
Distribution · 206 analyzed
The owner relies heavily on a small set of pre-written templates. Positive reviews receive a standard 'wonderful review' script, while negative reviews receive a standardized apology that fails to address specific allegations of neglect or abuse.
Personalized based on this facility's data
Key Review Excerpts
“The difference is night and day. While no facility is perfect, this is as good as it gets. My dad gets good care. The staff seem to care about him.”
“My grandmother was transferred here directly from the hospital, and the transition was handled dangerously poorly. When she arrived, the facility did not have her medical records or pain medication orders.”
“The staff are so warm and friendly. Therapy dis a great job to get me to be able to go home and I'm grateful to them”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
11
measures
2
measures
4
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents vaccinated for pneumonia
Residents whose bladder or bowel control got worse
Residents vaccinated for the flu
Residents who lost too much weight
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Families have filed multiple complaints against this facility, with concerns spanning recent years including a serious safety issue in late 2024. The most recurring problems involve medication management, fire safety systems, and basic care planning. While the facility has correction dates for all deficiencies, the pattern of repeated issues across medication services and safety systems, combined with ongoing family complaints, suggests persistent operational challenges that warrant careful consideration.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Administration Deficiencies
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Federal Penalties
Fine
Apr 18, 2026
$8,771
Fine
Oct 31, 2025
$14,069
1424 Fallbrook Dr Opco LLC
for profit
CAPSTONE HC MANAGEMENT LLC
SHANAE P WILBERT
Owners
Undisclosed
Ownership Data Not Available · Organization
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EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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