Fall Creek Rehabilitation and Healthcare Center
14949 Mesa Dr, Humble, TX 77396 · Harris County · 126 certified beds · avg 84 residents/day · certified since Dec 13, 2016
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Apr 13, 2025 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 14, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 13, 2025 · F-0691 · triggered by a complaint
The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy.
Why it matters: Poor ostomy care leads to skin breakdown, infection, pain, and embarrassment for the resident.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 14, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 5, 2025 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 6, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 5, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 6, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Mar 13, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 15, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, repeated · Mar 13, 2024 · F-0602 · triggered by a complaint
The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds.
Why it matters: Residents can lose money, jewelry, or cherished possessions to theft or misuse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 21, 2023 (Past Non-Compliance)
▲ Immediate jeopardy, repeated · Mar 13, 2024 · F-0761 · triggered by a complaint
The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Why it matters: Unlocked or mislabeled medications can be taken by the wrong person or given in error, with serious consequences.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 21, 2023 (Past Non-Compliance)
All citations in the current public record (22)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 16, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Apr 1, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 1, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 8, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 30, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 13, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Apr 13, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint |
| Apr 13, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Feb 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 13, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 13, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Mar 13, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 7, 2024 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Mar 7, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Dec 8, 2022 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 8, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 8, 2022 | C · Minimal risk, facility-wide | The facility did not dispose of garbage and refuse properly. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 3 | 0 | E |
| 2024 | 5 | 3 | K ▲ |
| 2025 | 11 | 4 | K ▲ |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $48,555.
| Date | Type | Amount / length |
|---|---|---|
| Apr 13, 2025 | Fine | $33,683 |
| Feb 5, 2025 | Fine | $14,872 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.12 | 3.46 | 3.95 | bottom 32% in Texas; bottom 18% in the U.S. |
| Registered Nurse hours | 0.10 | 0.44 | 0.69 | bottom 1% in Texas; bottom 1% in the U.S. |
| Weekend total nurse staffing | 2.69 | 3.04 | 3.50 | bottom 29% in Texas; bottom 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.12 | 0.34 | 0.48 | bottom 5% in Texas; bottom 3% in the U.S. |
| Total nursing staff turnover (%) | 65.6 | 55.3 | 45.8 | bottom 24% in Texas; bottom 9% in the U.S. |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.25, RN 0.11, weekend 2.81. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bullpen Family Venture, LP | Organization | 5% or Greater Indirect Ownership Interest | — | 12/12/2015 |
| Bullpen One, LLC | Organization | 5% or Greater Direct Ownership Interest | 10% | 12/12/2015 |
| Edaws Investment Group, LP | Organization | 5% or Greater Direct Ownership Interest | 90% | 12/12/2015 |
| Reed, Michael | Individual | 5% or Greater Indirect Ownership Interest | — | 12/12/2015 |
| Reed, Stacie | Individual | 5% or Greater Indirect Ownership Interest | — | 12/12/2015 |
| Threadgill, Forrest | Individual | 5% or Greater Indirect Ownership Interest | — | 10/01/2020 |
| Threadgill, Morgan | Individual | 5% or Greater Indirect Ownership Interest | — | 10/01/2020 |
| Threadgill, Sharlyn | Individual | 5% or Greater Indirect Ownership Interest | — | 10/01/2020 |
| Clearlake Healthcare Realty, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 10/01/2020 |
| Clearlake Healthcare Realty, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
| Compton, Charles | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 10/01/2020 |
| Compton, Charles | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
| Compton, James | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 10/01/2020 |
| Compton, James | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
| Compton, Kris | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 10/01/2020 |
| Compton, Kris | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
| Compton3 Holdings, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 10/01/2020 |
| Compton3 Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
| Lanier, Julia | Individual | ADP of the SNF | NOT APPLICABLE | 06/12/2018 |
| Martel Healthcare Management LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 10/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Which staff are trained in ostomy care, and how often is that care provided and checked?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you handle room assignments and roommate requests, and do residents get advance written notice before any move?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Oakmont Healthcare and Rehabilitation of Humble | 3.1 mi | Humble, TX | ★★☆☆☆ | 1/5 | |
| Focused Care at Humble | 4.0 mi | Humble, TX | ★☆☆☆☆ | 1/5 | abuse |
| Park Manor of Humble | 4.3 mi | Humble, TX | ★★★★☆ | 3/5 | |
| Crimson Heights Health & Wellness | 4.5 mi | Humble, TX | ★★★☆☆ | 2/5 | |
| Deerbrook Skilled Nursing and Rehab Center | 4.7 mi | Humble, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Kingwood Rehabilitation and Healthcare Center | 8.7 mi | Kingwood, TX | ★☆☆☆☆ | 1/5 | |
| Ashford Gardens | 9.1 mi | Houston, TX | ★★☆☆☆ | 2/5 | |
| Highland Park Care Center | 9.2 mi | Houston, TX | ★★☆☆☆ | 1/5 | |
| Bridgecrest Rehabilitation Suites | 9.7 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| Caraday of Houston | 9.9 mi | Houston, TX | ★☆☆☆☆ | 1/5 | |
| Avir at Veterans Memorial | 10.6 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuse |
| West Janisch Health Care Center | 10.8 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676412.