Fallbrook Rehabilitation and Care Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 115 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (24 vs median 8.0)
- High staff turnover (77%)
- High RN turnover (86%)
Bottom 25% in Texas · Below recommended RN staffing · Very high staff turnover · $173,479 in fines
What this means for your family
While recent tours suggest a clean and well-managed facility under new leadership, the frequency of severe medical neglect reports—specifically regarding bedsores and medication errors—is alarming. If you choose this facility, you must implement a rigorous daily check-in routine to personally verify that call lights are being answered and medications are being administered.
Google Reviews
Google Reviews
115 reviews on Google“Families should exercise extreme caution, as recent reviews frequently report severe medical neglect, including untreated bedsores, sepsis, and failure to administer essential medications. While some recent visitors praise a new management team and a clean, renovated atmosphere, these positive experiences are overshadowed by serious allegations of understaffing and patient safety risks.”
Quality Themes
Tap a score for detailsStrengths
- Recent building renovations and cleanliness
- Welcoming atmosphere during tours
- Engaging activity programs
- Professionalism in the admissions/administrative team
Concerns
- Severe medical neglect and wound care failures (mentioned by 3 reviewers)
- Failure to administer medications on time (mentioned by 3 reviewers)
- Unresponsive call lights and slow staff response (mentioned by 4 reviewers)
- Inadequate hygiene and room cleanliness (mentioned by 3 reviewers)
- Understaffing and lack of communication (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 119 analyzed
How They Respond to Reviews
The owner relies heavily on a small set of pre-written templates to respond to reviews. While they attempt to personalize some responses by including the reviewer's name, the core message remains a repetitive, copy-paste script.
Questions for Your Tour
- 1We noticed the recent renovations and how clean the building looks; how do you ensure that this level of cleanliness is maintained in the resident rooms every day?
- 2Can you walk us through your specific process for medication administration and how you track that it is given exactly on schedule?
- 3How does the nursing team prioritize responding to call lights, especially during busy shift changes or overnight?
- 4What is your protocol for managing wound care and ensuring that medical treatments are followed precisely as prescribed by doctors?
- 5We've heard great things about your activity programs; could you tell us more about what a typical day of engagement looks like for the residents?
- 6How do you ensure consistent and clear communication between the nursing staff and family members regarding a resident's daily health updates?
Personalized based on this facility's data
Key Review Excerpts
“The new team at Fallbrook has brought a lot of vibrance and kindness to the residents there. The remodel is beautiful and the energy is great.”
“She was left in the same gown for a week without a proper bath, her room was never cleaned and call lights were ignored or dismissed without action.”
“I cannot speak highly enough of Tierra (Activity Director) at Fallbrook Rehabilitation and Care Center. From the moment we walked in, we were greeted with warmth and professionalism.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
8
measures
3
measures
Residents vaccinated for pneumonia
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents whose walking got worse
Residents on antipsychotic medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed numerous complaints triggering 31 deficiencies, indicating ongoing concerns about care quality. The facility has persistent issues with medication management, daily living assistance, and care planning that recur across multiple surveys and recent dates. While all deficiencies show correction dates, the pattern of repeated problems in core care areas, particularly medication services appearing in 2022, 2023, and 2025, suggests systemic challenges that warrant careful consideration during any visit.
Feb 27, 2026Complaint2
Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Jan 14, 2026Complaint3
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Jan 5, 2026Complaint1
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Nov 20, 2025Complaint1
Pharmacy Service Deficiencies
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.
Oct 10, 2025Complaint2
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Sep 8, 2025Complaint5
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Federal Penalties
Fine
Feb 27, 2026
$12,460
Payment Denial
Aug 16, 2025
24-day denial
Fine
Feb 11, 2024
$46,008
Fine
Jul 5, 2023
$127,471
Ownership & Operations
Who Operates This Facility
Frio Hospital District
for profit
CRESCENT MOON DR HEATHCARE LLC
RAY BAKER
Ownership & Management
Owners
Frio Hospital District
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
115 reviews from families & visitors
Official Website
Visit fallbrookrehabandcarecenter.com
Medicare data downloads
Original nursing home datasets
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