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Complaint Investigation

Fallbrook Rehabiliation And Care Center

August 16, 2025 · Houston, TX · 10851 Crescent Moon Dr
Citations 1
CMS Rating 1/5
Beds 202
Provider ID 455815
Healthcare Facility
Fallbrook Rehabiliation And Care Center
Houston, TX  ·  View full profile →
Inspection Summary

Fallbrook Rehabiliation and Care Center in Houston, TX — inspection on August 16, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Immediate Jeopardy

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.

Facility ID:

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.


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