Cycle 1
Health 2025-04-11 · Fire 2025-04-11
25 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Houston, TX
Fallbrook Rehabiliation and Care Center
1-star overall rating with 1-star inspections with $173,479 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
10851 Crescent Moon Dr, Houston, TX
(281) 955-4100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
202
Certified beds
Average residents
61
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-05-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
0.80
Licensed practical nurse staffing
Aide hours / resident day
1.89
Nurse aide staffing
Weekend hours
2.77
Weekend nurse staffing
RN turnover
86%
Annual RN turnover
Total nurse turnover
77%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
97.1%
13.1 pts worse
|
93.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
97.9%
5.7 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.8% |
3.3%
0.5 pts worse
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.6% |
18.9%
12.7 pts worse
|
19.6%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
10.8%
4.1 pts worse
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.5% |
15.4%
13.1 pts worse
|
16.3%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
16.1%
8.9 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
15.0%
2.3 pts worse
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
4.2%
7.1 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.3% |
89.7%
16.4 pts worse
|
81.7%
8.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
12.0%
3 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.8% |
88.0%
24.2 pts worse
|
79.7%
15.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.9%
1.8 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-11 · Fire 2024-02-11
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-12-16 · Fire 2022-12-16
18 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-11
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-04-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-04-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-04-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-04-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-04-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-04-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-13
F · Potential for more than minimal harm
2024-02-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-08
F · Potential for more than minimal harm
2024-02-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-11
F · Potential for more than minimal harm
2024-02-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-11
F · Potential for more than minimal harm
2024-02-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-21
F · Potential for more than minimal harm
2024-02-11
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-02-17
F · Potential for more than minimal harm
2024-02-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-08
E · Potential for more than minimal harm
2024-02-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-02-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-27
C · Minimal harm
2024-02-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-08
F · Potential for more than minimal harm
2022-12-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-07
E · Potential for more than minimal harm
2025-11-20
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-03
J · Immediate jeopardy
2025-10-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-11
D · Potential for more than minimal harm
2025-10-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-11
E · Potential for more than minimal harm
2025-09-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-16
E · Potential for more than minimal harm
2025-09-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-09-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-09-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-09-16
J · Immediate jeopardy
2025-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-04-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-04-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-04
J · Immediate jeopardy
2024-02-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-15
H · Actual harm
2024-02-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-15
H · Actual harm
2024-02-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-11
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-15
D · Potential for more than minimal harm
2023-08-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-08-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-08-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-21
K · Immediate jeopardy
2023-08-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-09
K · Immediate jeopardy
2023-07-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-07-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-07-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-07-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-06
G · Actual harm
2022-12-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-16
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-01-16
Penalties and ownership
What sits behind the stars
$0
2025-08-16
Payment Denial
Payment Denial · denial start 2025-09-17 · 24 days
24 day denial
$46,008
2024-02-11
Fine
Fine · fine $46,008
Fine
$127,471
2023-07-05
Fine
Fine · fine $127,471
Fine
Ownership
Crescent Moon Dr Consulting LLC
Operational/Managerial Control · Organization
Frio Hospital District
5% Or Greater Direct Ownership Interest · Organization
Hiscox, Kenneth
Operational/Managerial Control · Individual
Miller, William
Operational/Managerial Control · Individual
Ruff, Michael
Corporate Officer · Individual
Vakil, Rupesh
Operational/Managerial Control · Individual
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#3
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