Fallbrook Rehab: Infection Control Failures - TX
Federal inspectors documented the infection control violations at Fallbrook Rehabilitation and Care Center in September after observing CNAs L and T provide care to Resident #1. The assistants committed multiple breaches of basic hygiene protocols designed to prevent the spread of germs between patients.
The CNAs first used gloves from their uniform pockets instead of taking fresh ones from the glove box in their care setup. They then cleaned the resident without removing the dirty gloves, washing their hands, or putting on clean gloves before applying a new incontinent brief.
CNA L compounded the violations by wiping urine from the resident's low-loss air mattress with peri wipes instead of disinfectant. The cleaning method left germs on the mattress surface.
The Director of Nursing told inspectors the assistants "should not have used gloves from their uniform pockets because it would lead to cross-contamination and the spread of germs." She explained they should have removed dirty gloves after cleaning, washed or sanitized their hands, then put on clean gloves before applying the brief.
The nursing director said CNA L "should have disinfected the low-loss air mattress instead of wiping it with a peri wipe, which was an infection control issue because the germs were still present on the mattress."
During a September 5 interview, the facility administrator confirmed the violations. He said the CNAs "should have washed their hands before they donned clean gloves and provided care for Resident #1."
The administrator explained the assistants "should have taken gloves from the glove box on their incontinent care setup, not from their uniform pockets, because of infection control, and they could spread germs from one resident to another."
He described the proper protocol: remove gloves used for cleaning, wash or sanitize hands, put on clean gloves, then apply the fresh brief.
The administrator called CNA L's mattress cleaning "an infection control issue" because peri wipes don't kill germs like disinfecting wipes do.
Fallbrook's own policies require the exact procedures the CNAs ignored. The facility's hand hygiene policy, dated September 2021, states all staff must "perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors."
The policy specifically addresses glove use: "The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves."
A March 2023 infection control policy emphasizes the facility's commitment to "maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections."
The violations occurred despite clear written protocols designed to protect vulnerable nursing home residents from preventable infections. The assistants' actions created multiple opportunities for germs to spread from contaminated gloves to the resident's body, bedding, and potentially other patients through cross-contamination.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" affecting "few" residents. The citation fell under federal infection prevention and control standards requiring nursing homes to establish and maintain programs preventing the development and transmission of communicable diseases.
The inspection was conducted in response to a complaint, though the report doesn't specify what prompted the federal review of the facility's infection control practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fallbrook Rehabiliation and Care Center from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Fallbrook Rehabiliation and Care Center in Houston, TX was cited for violations during a health inspection on September 8, 2025.
The assistants committed multiple breaches of basic hygiene protocols designed to prevent the spread of germs between patients.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.