Fallbrook Rehabiliation and Care Center
Open-data reference.
Fallbrook Rehabiliation and Care Center is a government - hospital district facility in Houston, TX with 202 certified beds and a 1-star overall CMS rating. The facility has 48 deficiency records on file. Total penalties: $173K.
10851 Crescent Moon Dr, Houston, TX 77064
Phone: 2819554100
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 455815
- Ownership
- Government - Hospital district
- Provider Type
- Medicare and Medicaid
- Beds
- 202
- Residents
- 61
- In Hospital
- No
- County
- Harris
- Last Inspection
- Apr 11, 2025
Staffing Data
- RN Hours
- 0.52 (nat'l avg: 0.68)
- LPN Hours
- 0.80
- CNA Hours
- 1.89
- Total Nursing Hours
- 3.21 (nat'l avg: 3.89)
- PT Hours
- 0.08
- Nursing Turnover
- 77.2%
- RN Turnover
- 85.7%
What the CMS Record Reveals About Fallbrook Rehabiliation and Care Center
Fallbrook Rehabiliation and Care Center operates 202 certified beds in Houston, TX with approximately 61 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (1★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 48 deficiency records from recent surveys, of which 8 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $173K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.21 total nursing hours per resident day (national average 3.89), with RN coverage at 0.52 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Government - Hospital district" ownership and operating as a "Medicare and Medicaid" provider, Fallbrook Rehabiliation and Care Center falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 77.2%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (48 most recent)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Dec 3, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 11, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Oct 11, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Sep 16, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 16, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 16, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 16, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Sep 16, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 17, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 15, 2025
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 15, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Apr 15, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 15, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 15, 2025
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Apr 4, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 15, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 15, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 15, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 15, 2024
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 15, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 15, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 15, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 15, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Feb 15, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 21, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 21, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 21, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 21, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 9, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Jul 6, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 6, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 6, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Jul 6, 2023
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Jan 16, 2023
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Jan 16, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jan 16, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jan 16, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 16, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 16, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 16, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 16, 2023
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Category: Resident Rights Deficiencies
Corrected: Jan 16, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 25.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 84.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 73.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 28.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 31.6% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 92.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 63.8% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 11.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 17.3% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 14.9% | Yes |
Penalty History 2 penalties totaling $173K
| Date | Type | Amount |
|---|---|---|
| Aug 16, 2025 | Payment Denial | - |
| Feb 11, 2024 | Fine | $46K |
| Jul 5, 2023 | Fine | $127K |
| Feb 28, 2023 | Fine | $5K |
| Feb 21, 2023 | Fine | $5K |
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Frequently Asked Questions
What is the overall CMS rating for Fallbrook Rehabiliation and Care Center?
What are the staffing levels at Fallbrook Rehabiliation and Care Center?
How many beds does Fallbrook Rehabiliation and Care Center have?
Does Fallbrook Rehabiliation and Care Center have any deficiencies on record?
Has Fallbrook Rehabiliation and Care Center received any fines or penalties?
Who owns Fallbrook Rehabiliation and Care Center?
When was Fallbrook Rehabiliation and Care Center last inspected?
What quality measures are tracked for Fallbrook Rehabiliation and Care Center?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.