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Fallbrook Rehabiliation and Care Center

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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

1/5

Health Inspection

1/5

Staffing

1/5

Quality Measures

3/5

Long-Stay Quality

3/5

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)

E — Pattern - Minimal harm Nov 20, 2025 Tag: 0761

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

J — Isolated - Jeopardy Oct 10, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 11, 2025

D — Isolated - Minimal harm Oct 10, 2025 Tag: 0580

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

D — Isolated - Minimal harm Sep 8, 2025 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Sep 16, 2025

D — Isolated - Minimal harm Sep 8, 2025 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Sep 16, 2025

D — Isolated - Minimal harm Sep 8, 2025 Tag: 0690

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

E — Pattern - Minimal harm Sep 8, 2025 Tag: 0677

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

E — Pattern - Minimal harm Sep 8, 2025 Tag: 0550

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

J — Isolated - Jeopardy Aug 16, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 17, 2025

E — Pattern - Minimal harm Apr 11, 2025 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0814

Dispose of garbage and refuse properly.

Category: Nutrition and Dietary Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0755

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

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0690

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

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0689

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

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0688

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

E — Pattern - Minimal harm Apr 11, 2025 Tag: 0677

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

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0656

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

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0655

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

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0583

Keep residents' personal and medical records private and confidential.

Category: Resident Rights Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Apr 11, 2025 Tag: 0558

Reasonably accommodate the needs and preferences of each resident.

Category: Resident Rights Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Apr 2, 2025 Tag: 0755

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

D — Isolated - Minimal harm Feb 11, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Feb 15, 2024

D — Isolated - Minimal harm Feb 11, 2024 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Feb 15, 2024

D — Isolated - Minimal harm Feb 11, 2024 Tag: 0690

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

J — Isolated - Jeopardy Feb 11, 2024 Tag: 0689

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

E — Pattern - Minimal harm Feb 11, 2024 Tag: 0688

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

H — Pattern - Actual harm Feb 11, 2024 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Feb 15, 2024

H — Pattern - Actual harm Feb 11, 2024 Tag: 0677

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

E — Pattern - Minimal harm Feb 11, 2024 Tag: 0656

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

D — Isolated - Minimal harm Feb 11, 2024 Tag: 0761

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

D — Isolated - Minimal harm Aug 18, 2023 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Aug 21, 2023

D — Isolated - Minimal harm Aug 18, 2023 Tag: 0842

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

D — Isolated - Minimal harm Aug 18, 2023 Tag: 0656

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

D — Isolated - Minimal harm Aug 18, 2023 Tag: 0641

Ensure each resident receives an accurate assessment.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Aug 21, 2023

K — Pattern - Jeopardy Aug 8, 2023 Tag: 0755

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

E — Pattern - Minimal harm Jul 5, 2023 Tag: 0921

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

D — Isolated - Minimal harm Jul 5, 2023 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Jul 6, 2023

K — Pattern - Jeopardy Jul 5, 2023 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 6, 2023

E — Pattern - Minimal harm Jul 5, 2023 Tag: 0623

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

D — Isolated - Minimal harm Dec 16, 2022 Tag: 0868

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Category: Administration Deficiencies

Corrected: Jan 16, 2023

E — Pattern - Minimal harm Dec 16, 2022 Tag: 0761

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

E — Pattern - Minimal harm Dec 16, 2022 Tag: 0759

Ensure medication error rates are not 5 percent or greater.

Category: Pharmacy Service Deficiencies

Corrected: Jan 16, 2023

E — Pattern - Minimal harm Dec 16, 2022 Tag: 0755

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

G — Isolated - Actual harm Dec 16, 2022 Tag: 0692

Provide enough food/fluids to maintain a resident's health.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 16, 2023

D — Isolated - Minimal harm Dec 16, 2022 Tag: 0656

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

D — Isolated - Minimal harm Dec 16, 2022 Tag: 0644

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

D — Isolated - Minimal harm Dec 16, 2022 Tag: 0641

Ensure each resident receives an accurate assessment.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 16, 2023

E — Pattern - Minimal harm Dec 16, 2022 Tag: 0584

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

Frequently Asked Questions

What is the overall CMS rating for Fallbrook Rehabiliation and Care Center?
Fallbrook Rehabiliation and Care Center has an overall CMS rating of 1 out of 5 stars. This rating combines health inspection results (1★), staffing levels (1★), and quality measures (3★).
What are the staffing levels at Fallbrook Rehabiliation and Care Center?
Fallbrook Rehabiliation and Care Center reports 3.21 total nursing hours per resident day (national average: 3.89). RN hours are 0.52 per resident day (national average: 0.68). Nursing staff turnover is 77.2%.
How many beds does Fallbrook Rehabiliation and Care Center have?
Fallbrook Rehabiliation and Care Center has 202 certified beds with approximately 61 residents. The facility is located at 10851 Crescent Moon Dr, Houston, TX 77064.
Does Fallbrook Rehabiliation and Care Center have any deficiencies on record?
Yes, Fallbrook Rehabiliation and Care Center has 48 deficiencies on record from recent inspections. Of these, 8 are classified as causing actual harm or jeopardy.
Has Fallbrook Rehabiliation and Care Center received any fines or penalties?
Yes, Fallbrook Rehabiliation and Care Center has received 2 penalties totaling $173K.
Who owns Fallbrook Rehabiliation and Care Center?
Fallbrook Rehabiliation and Care Center is classified as "Government - Hospital district" ownership. The facility type is "Medicare and Medicaid".
When was Fallbrook Rehabiliation and Care Center last inspected?
The most recent health inspection for Fallbrook Rehabiliation and Care Center was on Apr 11, 2025. The facility received a health inspection rating of 1 out of 5 stars.
What quality measures are tracked for Fallbrook Rehabiliation and Care Center?
Fallbrook Rehabiliation and Care Center is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

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.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial