Fallbrook Rehabiliation And Care Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
report during morning clinical meetings three times weekly for four weeks, then weekly for eight weeks. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from
the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. * Monitoring of the plan of removal included the following: Record review of an Audit/Monitoring dated 08/11/25-08/14/25 revealed residents were reviewed for change in condition, actions taken to address change in condition. The document reflected if the resident were sent out via 911 or non-emergent transportation, was there any delays, comments/corrective action. There were no identified concerns in the audit. Record review of the Summary Report of Education dated 08/14/25 revealed all facility staff were educated on Notifications of Change in Condition by the DON and Senior Administrator.
The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of the Summary Report of Education dated 08/14/25 revealed all licensed staff were educated on Changes of condition and seeking immediate medical care as to not delay services by calling 911 if needed for transportation as appropriate for the identified change in condition by
the DON. The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of Summary Report of Education dated 08/15/25 revealed licensed staff were educated on Monitoring and assessment to be done when a resident who is diabetic has a change in condition by the DON. The document revealed in part, Hypoglycemia Management-It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode (Definition, Policy explanation, Compliance guidelines, asymptomatic and responsive residents, symptomatic (lethargic, drowsy) but responsive (conscious) residents). Record review of In-service Summary/Report of Education of 1:1 with the DON and RN A dated 08/14/25 revealed RN A was educated
on change of condition-monitor resident vital signs, document-all-clinical changes, monitor resident until 911 arrives, document time start and finish, call NP/MD, DON, and RP. Interviews were conducted with staff
on 08/14/25 between 5:35 a.m. until 12:00 p.m. including RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q were able to explain the importance of monitoring the residents that had a change in condition, calling 911 when the residents have a change in condition (high/low blood sugar and high/low blood pressures), taking residents vitals until 911 arrived, staying with the resident until 911 arrived, and documenting all changes. The Administrator was informed
the Immediate Jeopardy was removed on 08/16/2025 at 12:02 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
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Fallbrook Rehabiliation and Care Center in Houston, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Houston, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Fallbrook Rehabiliation and Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.