Cycle 1
Health 2025-05-30 · Fire 2025-05-30
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Humble, TX
Fall Creek Rehabilitation and Healthcare Center
1-star overall rating with 1-star inspections with $48,555 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
14949 Mesa DR, Humble, TX
(281) 902-4152
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-12-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.16
Registered nurse staffing
LPN hours / resident day
1.17
Licensed practical nurse staffing
Aide hours / resident day
1.90
Nurse aide staffing
Weekend hours
2.96
Weekend nurse staffing
RN turnover
60%
Annual RN turnover
Total nurse turnover
74%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.2 |
2.1
2.1 pts worse
|
1.9
2.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
97.9%
1 pts worse
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
3.3%
5.2 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.9% |
3.3%
0.4 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.5% |
18.9%
14.4 pts better
|
19.6%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
10.8%
8.5 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.0% |
15.4%
9.6 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
16.1%
5.5 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
15.0%
3.1 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 11.9% |
4.2%
7.7 pts worse
|
5.1%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
89.7%
5.3 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
12.0%
1.1 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
88.0%
5.5 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.9%
1.1 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-30
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-02
F · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-28
F · Potential for more than minimal harm
2024-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-28
E · Potential for more than minimal harm
2022-12-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-05-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-02
K · Immediate jeopardy
2025-04-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-14
K · Immediate jeopardy
2025-04-13
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-04-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-14
J · Immediate jeopardy
2025-02-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-06
J · Immediate jeopardy
2025-02-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-06
K · Immediate jeopardy
2024-03-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-15
K · Immediate jeopardy
2024-03-13
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-21
K · Immediate jeopardy
2024-03-13
F761 · Pharmacy Service Deficiencies
Health
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 2023-11-21
E · Potential for more than minimal harm
2024-03-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-03
E · Potential for more than minimal harm
2022-12-08
F761 · Pharmacy Service Deficiencies
Health
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 2022-12-14
D · Potential for more than minimal harm
2022-12-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-14
C · Minimal harm
2022-12-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-12-14
Penalties and ownership
What sits behind the stars
$33,683
2025-04-13
Fine
Fine · fine $33,683
Fine
$14,872
2025-02-05
Fine
Fine · fine $14,872
Fine
Ownership
Edaws Investment Group, LP
5% Or Greater Direct Ownership Interest · Organization
Bullpen One, LLC
5% Or Greater Direct Ownership Interest · Organization
Bullpen Family Venture, LP
5% Or Greater Indirect Ownership Interest · Organization
Clearlake Healthcare Realty, LLC
5% Or Greater Mortgage Interest · Organization
Compton, Charles
5% Or Greater Mortgage Interest · Individual
Compton, James
5% Or Greater Mortgage Interest · Individual
Compton, Kris
5% Or Greater Mortgage Interest · Individual
Compton3 Holdings, LLC
5% Or Greater Mortgage Interest · Organization
Martel Healthcare Management LLC
5% Or Greater Mortgage Interest · Organization
Martel, Michael
5% Or Greater Mortgage Interest · Individual
Reed, Michael
5% Or Greater Indirect Ownership Interest · Individual
Reed, Stacie
5% Or Greater Indirect Ownership Interest · Individual
Suter, Rachel
Operational/Managerial Control · Individual
The Smithers Management Trust
5% Or Greater Mortgage Interest · Organization
Threadgill, Forrest
5% Or Greater Indirect Ownership Interest · Individual
Threadgill, Morgan
5% Or Greater Indirect Ownership Interest · Individual
Threadgill, Sharlyn
5% Or Greater Indirect Ownership Interest · Individual
Threadgill, Sharlyn
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Oakmont Healthcare and Rehabilitation of Humble
Humble, TX
0-star overall rating with 0-star inspections with Special Focus status with $418,615 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Focused Care At Humble
Humble, TX
3-star overall rating with 2-star inspections with $19,410 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Park Manor Of Humble
Humble, TX
4-star overall rating with 3-star inspections with $181,138 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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