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Complaint Investigation

Fallbrook Rehabilitation And Care Center

October 10, 2025 · Houston, TX · 10851 Crescent Moon Dr
Citations 2
CMS Rating 1/5
Beds 202
Provider ID 455815
Healthcare Facility
Fallbrook Rehabilitation And Care Center
Houston, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Fallbrook Rehabilitation and Care Center in Houston, TX — inspection on October 10, 2025.

Found 2 citations. 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

FF0580
Resident Rights Deficiencies
Potential for More Than Minimal Harm

her he was in the hospital.

Record review of the facility's Notification of Changes policy, date reviewed/revised 12/08/24, revealed in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.2.

Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status.

This may include: a.

Life-threatening conditions, or b.

Clinical complications.Additional considerations: 1.

Competent individuals.c.

When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Fallbrook Rehabiliation and Care Center

10851 Crescent Moon Dr Houston, TX 77064

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

11:53 a.m. and 12:09 p.m. and on 10/09/25, between 2:01 p.m. and 3:30 p.m., with staff from all shifts (6:00 a.m.to 6:00 p.m., 6:00 p.m. to 6:00 a.m., 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.).

Staff interviewed included the following: Nurses D, E, and F, MAs A and B, and CNAs C, D, E, F, G, and H.

All staff interviewed verbalized an understanding of being alert for signs of a change in a resident's condition, signs and changes to look for, reporting and following up with the nurse, and following chain in command when there is a concern.

The DON was informed that the Immediate Jeopardy was removed on 10/09/25 at 3:34 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 was 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 Rehabilitation and Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

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.