Fall Creek Rehabilitation and Healthcare Center
14949 Mesa DR, Humble, TX 77396
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Follow this homeFall Creek Rehabilitation and Healthcare Center is a nursing home in Humble, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionJuly 17, 2026 (3 months ago)
- Health citations since March 7, 202426 (Texas average 28)
- Fines in the past three years2, $48,555 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on July 26, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS has cited this home for F0677 3 times since 2025.
Health inspection on July 17, 2026
6 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 6 citations
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 20, 2026.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 20, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 20, 2026.
CMS has cited this home for F0656 4 times since 2024.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on July 20, 2026.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 20, 2026.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on July 20, 2026.
Fire safety inspection on July 17, 2026
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on July 17, 2026.
Health inspection on June 16, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0559. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on July 16, 2026.
CMS update of May 27, 2026
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on April 1, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 3, 2026.
CMS has cited this home for F0600 2 times since 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on April 3, 2026.
CMS update of January 14, 2026
Fine
CMS changed the fine from April 13, 2025 from $51,820 to $33,683.
CMS update of November 20, 2025
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on July 8, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 14, 2025.
Health inspection on May 30, 2025
5 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 5 citations
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on June 2, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 2, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 2, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on June 2, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 2, 2025.
Fire safety inspection on May 30, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0929. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
CMS lists it as corrected on June 2, 2025.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 2, 2025.
CMS update of May 28, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Health inspection on April 13, 2025
3 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $33,683 on April 13, 2025.
Show the 3 citations
Citation F0580. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 14, 2025.
Citation F0691. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on April 14, 2025.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 14, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on February 5, 2025
2 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $14,872 on February 5, 2025.
Show the 2 citations
Citation F0656. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on February 6, 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 6, 2025.
CMS update of May 29, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Health inspection on March 13, 2024
3 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
Show the 3 citations
Citation F0600. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on February 15, 2024.
Citation F0602. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on November 21, 2023.
Citation F0761. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 21, 2023.
Health inspection on March 7, 2024
2 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 2 citations
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 3, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 3, 2024.
Fire safety inspection on March 7, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 28, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 28, 2024.
CMS update of January 31, 2024
Ownership
CMS no longer lists a chain for this home.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (281) 902-4152
- Last standard health inspection
- July 17, 2026 (3 months ago)
- Certified beds
- 126
- Residents per day, on average
- 84.9
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Ltc of Fall Creek LLC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (26 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BULLPEN ONE, LLC5% or greater direct ownership interest · 10% · since 12/12/2015
- EDAWS INVESTMENT GROUP, LP5% or greater direct ownership interest · 90% · since 12/12/2015
- BULLPEN FAMILY VENTURE, LP5% or greater indirect ownership interest · no percentage provided · since 12/12/2015
- REED, MICHAEL5% or greater indirect ownership interest · no percentage provided · since 12/12/2015
- REED, STACIE5% or greater indirect ownership interest · no percentage provided · since 12/12/2015
Show 5 more
- THREADGILL, FORREST5% or greater indirect ownership interest · no percentage provided · since 10/01/2020
- THREADGILL, MORGAN5% or greater indirect ownership interest · no percentage provided · since 10/01/2020
- THREADGILL, SHARLYN5% or greater indirect ownership interest · no percentage provided · since 10/01/2020
- SUTER, RACHELOperational/managerial control · not applicable · since 06/27/2016
- THREADGILL, SHARLYNOperational/managerial control · not applicable · since 10/01/2020
Questions
When was Fall Creek Rehabilitation and Healthcare Center last inspected?
CMS lists July 17, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Fall Creek Rehabilitation and Healthcare Center have?
CMS lists 26 health citations since March 7, 2024. CMS also calls these deficiencies.
Has Fall Creek Rehabilitation and Healthcare Center been fined?
CMS lists 2 fines in the past three years, $48,555 in total.
What is the CMS star rating of Fall Creek Rehabilitation and Healthcare Center?
Its CMS overall star rating is 1 of 5.
Is Fall Creek Rehabilitation and Healthcare Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.