01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-30 | 6 | 2025-05-30 | 2 |
| Cycle 2 | 2024-03-07 | 10 | 2024-03-07 | 2 |
| Cycle 3 | 2022-12-08 | 6 | 2022-12-08 | 1 |
CMS CCN 6764122026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Fall Creek Rehabilitation And Healthcare Center
14949 Mesa Dr · Humble, TX 77396 · Harris County
Certified beds126CMS provider file
Recent citation rows27current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
27 rows in the current release
7 rows carry G–L scope/severity codes; 7 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-16 · HEALTHF0559Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-07-16 · complaint2026-04-01 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-03 · complaint2026-04-01 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-03 · complaint2025-07-08 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-07-14 · complaint2025-05-30 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2025-06-022025-05-30 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-02 · complaint2025-05-30 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-06-02 · complaint2025-05-30 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-06-022025-05-30 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-06-022025-05-30 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-022025-05-30 · FIREK0929Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Correction field: Deficient, Provider has date of correction · 2025-06-022025-04-13 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-04-14 · complaint2025-04-13 · HEALTHF0580Severity K · pattern of immediate jeopardy
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.
Correction field: Deficient, Provider has date of correction · 2025-04-14 · complaint2025-04-13 · HEALTHF0691Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-04-14 · complaint2025-02-05 · HEALTHF0656Severity J · isolated immediate jeopardy
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.
Correction field: Deficient, Provider has date of correction · 2025-02-06 · complaint2025-02-05 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-02-06 · complaint2024-03-13 · HEALTHF0600Severity K · pattern of immediate jeopardy
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.
Correction field: Past Non-Compliance · 2024-02-15 · complaint2024-03-13 · HEALTHF0602Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Past Non-Compliance · 2023-11-21 · complaint2024-03-13 · HEALTHF0761Severity K · pattern of immediate jeopardy
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.
Correction field: Past Non-Compliance · 2023-11-21 · complaint2024-03-07 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-04-03 · complaint2024-03-07 · HEALTHF0692Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2024-04-03 · complaint2024-03-07 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-03-282024-03-07 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-03-282022-12-08 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2022-12-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-04-13 | Fine | $33,683 | 0 |
| 2025-02-05 | Fine | $14,872 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BULLPEN ONE, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST10% · since 12/12/2015
- EDAWS INVESTMENT GROUP, LPOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST90% · since 12/12/2015
- BULLPEN FAMILY VENTURE, LPOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/12/2015
- REED, MICHAELIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/12/2015
- REED, STACIEIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/12/2015
- THREADGILL, FORRESTIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2020
- THREADGILL, MORGANIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2020
- THREADGILL, SHARLYNIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2020
- CLEARLAKE HEALTHCARE REALTY, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- COMPTON3 HOLDINGS, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- MARTEL HEALTHCARE MANAGEMENT LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- THE SMITHERS MANAGEMENT TRUSTOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- COMPTON, CHARLESIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- COMPTON, JAMESIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- COMPTON, KRISIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- MARTEL, MICHAELIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 10/01/2020
- SUTER, RACHELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/27/2016
- THREADGILL, SHARLYNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.25per resident day
RN hours0.11per resident day
Weekend nurse hours2.81per resident day
Staff turnover65.6%CMS reported field
06 / LOCAL RECORDS
Open the Humble ledger →Other published facilities nearby
Crimson Heights Health & Wellness118 beds · CMS overall 3/540 citation rowsDeerbrook Skilled Nursing And Rehab Center124 beds · CMS overall 1/539 citation rowsFocused Care At Humble134 beds · CMS overall 1/532 citation rowsOakmont Healthcare And Rehabilitation Of Humble134 beds · CMS overall 2/543 citation rowsPark Manor Of Humble125 beds · CMS overall 4/527 citation rows