Fallbrook Rehabilitation And Care Center
Fallbrook Rehabilitation 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.
Inspection Findings
transportation as appropriate for the identified change in condition by the DON.
The document
jeopardy to resident health or consults the resident's physician; and notifies consistent with his or her authority, resident's safety representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.