Home › Texas › Harris County › Fall Creek Rehabilitation and Healthcare Center
Fall Creek Rehabilitation and Healthcare Center
14949 Mesa Dr, Humble, TX 77396 · CMS Certification Number (CCN) 676412
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 24 in the last 3 inspection cycles (7 immediate jeopardy, 0 actual harm, 18 from complaints)
- Fire safety citations
- 5
- Fines (last 3 years)
- 2 fines, total $48,555
- Payment denials
- 0
- Most recent standard inspection
- May 30, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | May 30, 2025 | 8 | 3 | 5 |
| Cycle 2 | March 7, 2024 | 13 | 2 | 13 |
CMS weighted health inspection score: 138.5 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
24 health citations across 11 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 26, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has no plan of correction |
July 17, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has no plan of correction |
June 16, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0559 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/16/2026 |
April 1, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/03/2026 |
| D | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/03/2026 |
July 8, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/14/2025 |
May 30, 2025: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/02/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/02/2025 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/02/2025 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/02/2025 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/02/2025 |
April 13, 2025: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| K | F-0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/14/2025 |
| K | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/14/2025 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/14/2025 |
February 5, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/06/2025 |
| J | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/06/2025 |
March 13, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| K | F-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. Pharmacy Service Deficiencies | Complaint | Past Non-Compliance Corrected 11/21/2023 |
| K | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 11/21/2023 |
| K | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 02/15/2024 |
March 7, 2024: 2 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/03/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/03/2024 |
December 8, 2022: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| C | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/14/2022 |
| E | F-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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/14/2022 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/14/2022 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
5 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 05/30/2025 | E | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 06/02/2025 |
| 05/30/2025 | D | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/02/2025 |
| 03/07/2024 | F | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 03/28/2024 |
| 03/07/2024 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/28/2024 |
| 12/08/2022 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/22/2022 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| April 13, 2025 | Fine | $33,683 | — |
| February 5, 2025 | Fine | $14,872 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.25 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.11 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.27 | Not published | Not published |
| Nurse aide hours per resident per day | 1.88 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.81 | Not published | Not published |
| RN hours per resident per day, weekends | 0.12 | Not published | Not published |
| Total nursing staff turnover (%) | 65.6 | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Ltc of Fall Creek LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 126
- Average residents per day
- 84.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- None
- First approved for Medicare/Medicaid
- December 13, 2016
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
29 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| BULLPEN ONE, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 10% | undefined undefined, NaN |
| EDAWS INVESTMENT GROUP, LP | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 90% | undefined undefined, NaN |
| BULLPEN FAMILY VENTURE, LP | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| REED, MICHAEL | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| REED, STACIE | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| THREADGILL, FORREST | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| THREADGILL, MORGAN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| THREADGILL, SHARLYN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| CLEARLAKE HEALTHCARE REALTY, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON3 HOLDINGS, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL HEALTHCARE MANAGEMENT LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THE SMITHERS MANAGEMENT TRUST | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, CHARLES | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, JAMES | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, KRIS | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL, MICHAEL | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SUTER, RACHEL | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| THREADGILL, SHARLYN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITHERS, JEFFREY | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CLEARLAKE HEALTHCARE REALTY, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON3 HOLDINGS, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL HEALTHCARE MANAGEMENT LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THE SMITHERS MANAGEMENT TRUST | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, CHARLES | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, JAMES | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, KRIS | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LANIER, JULIA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL, MICHAEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SUTER, RACHEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Fall Creek Rehabilitation and Healthcare Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.