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🔎 Fall Creek Rehabilitation And Healthcare Center

Inspection Results


Inspection Overview

Fall Creek Rehabilitation And Healthcare Center has been cited for a total of 20 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: J

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-02-05
Correction Date: 2025-02-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2025-02-05
Correction Date: 2025-02-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: K

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

Survey Date: 2024-03-13
Correction Date: 2024-02-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: K

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

Survey Date: 2024-03-13
Correction Date: 2024-03-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: K

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.

Survey Date: 2024-03-13
Correction Date: 2023-11-21
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-03-07
Correction Date: 2024-04-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-03-07
Correction Date: 2024-04-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-12-08
Correction Date: 2022-12-14
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-12-08
Correction Date: 2022-12-14
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: C

Dispose of garbage and refuse properly.

Survey Date: 2022-12-08
Correction Date: 2022-12-14
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2021-09-23
Correction Date: 2021-10-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-09-23
Correction Date: 2021-10-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2021-09-23
Correction Date: 2021-10-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-09-23
Correction Date: 2021-10-21
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-03-30
Correction Date: 2021-04-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-01-20
Correction Date: 2021-01-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: H

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

Survey Date: 2021-01-20
Correction Date: 2021-01-25
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-01-20
Correction Date: 2021-01-25
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2019-10-25
Correction Date: 2019-11-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-10-25
Correction Date: 2019-11-11
Category: Pharmacy Service Deficiencies
From Complaint: N

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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**