Fall Creek Rehabilitation And Healthcare Center

Penalties

• Apr 13, 2025 — Fine ($33,683)
• Feb 5, 2025 — Fine ($14,872)

Inspection findings

1. Jun 16, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0559 Resident Rights Deficiencies

     Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

     Corrected Jul 16, 2026 · CMS health inspection

2. Apr 1, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Apr 3, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Apr 3, 2026 · CMS health inspection

3. Jul 8, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 14, 2025 · CMS health inspection

4. May 30, 2025 Health · 7 findings
   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jun 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Jun 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jun 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Jun 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jun 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 2, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Jun 2, 2025 · CMS fire safety

5. Apr 13, 2025 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Apr 14, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0580 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.

     Corrected Apr 14, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0691 Quality of Life and Care Deficiencies

     Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

     Corrected Apr 14, 2025 · CMS health inspection

6. Feb 5, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0656 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.

     Corrected Feb 6, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 6, 2025 · CMS health inspection

7. Mar 13, 2024 Health · 3 findings
   • Serious Scope/severity K Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Feb 15, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Nov 21, 2023 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0761 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.

     Corrected Nov 21, 2023 · CMS health inspection

8. Mar 7, 2024 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Apr 3, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0692 Quality of Life and Care Deficiencies

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

     Corrected Apr 3, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 28, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 28, 2024 · CMS fire safety

9. Dec 8, 2022 Health · 4 findings
   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 14, 2022 · CMS health inspection

   • Not serious Scope/severity E

     F0761 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.

     Corrected Dec 14, 2022 · CMS health inspection

   • Not serious Scope/severity C

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Dec 14, 2022 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Dec 22, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• COMPTON, CHARLES — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020
• COMPTON, CHARLES — adp of the snf, NOT APPLICABLE, since 10/01/2020
• COMPTON, JAMES — adp of the snf, NOT APPLICABLE, since 10/01/2020
• COMPTON, JAMES — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020
• COMPTON, KRIS — adp of the snf, NOT APPLICABLE, since 10/01/2020
• COMPTON, KRIS — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020
• LANIER, JULIA — adp of the snf, NOT APPLICABLE, since 06/12/2018
• MARTEL, MICHAEL — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020
• MARTEL, MICHAEL — adp of the snf, NOT APPLICABLE, since 10/01/2020
• REED, MICHAEL — 5% or greater indirect ownership interest, since 12/12/2015
• REED, STACIE — 5% or greater indirect ownership interest, since 12/12/2015
• SMITHERS, JEFFREY — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/28/2025
• SUTER, RACHEL — adp of the snf, NOT APPLICABLE, since 06/27/2016
• SUTER, RACHEL — operational/managerial control, NOT APPLICABLE, since 06/27/2016
• THREADGILL, FORREST — 5% or greater indirect ownership interest, since 10/01/2020
• THREADGILL, MORGAN — 5% or greater indirect ownership interest, since 10/01/2020
• THREADGILL, SHARLYN — 5% or greater indirect ownership interest, since 10/01/2020
• THREADGILL, SHARLYN — operational/managerial control, NOT APPLICABLE, since 10/01/2020
• BULLPEN FAMILY VENTURE, LP — 5% or greater indirect ownership interest, since 12/12/2015
• BULLPEN ONE, LLC — 5% or greater direct ownership interest, 10%, since 12/12/2015
• CLEARLAKE HEALTHCARE REALTY, LLC — adp of the snf, NOT APPLICABLE, since 10/01/2020
• CLEARLAKE HEALTHCARE REALTY, LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020
• COMPTON3 HOLDINGS, LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020
• COMPTON3 HOLDINGS, LLC — adp of the snf, NOT APPLICABLE, since 10/01/2020
• EDAWS INVESTMENT GROUP, LP — 5% or greater direct ownership interest, 90%, since 12/12/2015
• MARTEL HEALTHCARE MANAGEMENT LLC — adp of the snf, NOT APPLICABLE, since 10/01/2020
• MARTEL HEALTHCARE MANAGEMENT LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020
• THE SMITHERS MANAGEMENT TRUST — adp of the snf, NOT APPLICABLE, since 10/01/2020
• THE SMITHERS MANAGEMENT TRUST — 5% or greater mortgage interest, NOT APPLICABLE, since 10/01/2020