SNF

Fall Creek Rehabilitation and Healthcare Center

CCN: 676412 · Humble, TX 77396 · Harris County

Overview

Address
14949 Mesa DR, Humble, TX 77396
Phone
2819024152
Certified beds
126
Avg daily residents
77 (61% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare and Medicaid
Medicare/Medicaid since
2016-12-13
Setting
Urban
1 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 1/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 3/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 2/5
Short-Stay Quality Measures ★★★★★ 3/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 3.23 4.10 3.04 ≥ 3.48 Below floor
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 0.16 0.72 0.15 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 1.17 0.91 1.10 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 1.90 2.47 1.79 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.33 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.04 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
2.96
hrs / resident / day
RN (weekend)
0.14
hrs / resident / day
Total nurse (adjusted, weekend)
2.79
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
74.2%
annual
RN turnover
60.0%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.45
higher acuity than avg
Case-Mix Index Ratio
1.05
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-05-30 9 3 6 261 1 261
Cycle 2/3 (prior) 2024-03-07 7 2 7 197 1 197
Total weighted health score
245.0
lower is better

Deficiencies (19)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

1 A/B/C No actual harm — minor
11 D/E/F Actual harm — potential for minor
7 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0880 Provide and implement an infection prevention and control program. E 2025-07-08 2025-07-14
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2025-05-30 2025-06-02
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2025-05-30 2025-06-02
0583 Keep residents' personal and medical records private and confidential. D 2025-05-30 2025-06-02
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2025-05-30 2025-06-02
0759 Ensure medication error rates are not 5 percent or greater. D 2025-05-30 2025-06-02
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. E 2025-04-13 2025-04-14
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. K 2025-04-13 2025-04-14
0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. K 2025-04-13 2025-04-14
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. J 2025-02-05 2025-02-06
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2025-02-05 2025-02-06
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. K 2024-03-13 2024-02-15
0602 Protect each resident from the wrongful use of the resident's belongings or money. K 2024-03-13 2023-11-21
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. K 2024-03-13 2023-11-21
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2024-03-07 2024-04-03
0692 Provide enough food/fluids to maintain a resident's health. E 2024-03-07 2024-04-03
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2022-12-08 2022-12-14
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. E 2022-12-08 2022-12-14
0814 Dispose of garbage and refuse properly. C 2022-12-08 2022-12-14

Penalties (2)

Fines issued
2
last 3 years
Total fines
$48,555
Date Type Fine amount
2025-02-05 Fine $14,872
2025-04-13 Fine $33,683

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 12.4% Medicaid 59.7% Other 27.9%

Operating performance

Operating Margin
3.3%
Total Margin
4.0%
Occupancy Rate
73.5%
Cost per Resident Day
$49

Revenue & costs

Net Patient Revenue
$9.9M
Total Costs
$1.7M
Net Income
$398K

Balance sheet

Total Assets
$2.1M
Total Liabilities
$564K
Fund Balance
$1.6M
Current Ratio
3.68

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Owner / manager organizations (7)

Organization Role Association
BULLPEN ONE, LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 12/12/2015
EDAWS INVESTMENT GROUP, LP 5% OR GREATER DIRECT OWNERSHIP INTEREST since 12/12/2015
BULLPEN FAMILY VENTURE, LP 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 12/12/2015
CLEARLAKE HEALTHCARE REALTY, LLC 5% OR GREATER MORTGAGE INTEREST since 10/01/2020
COMPTON3 HOLDINGS, LLC 5% OR GREATER MORTGAGE INTEREST since 10/01/2020
MARTEL HEALTHCARE MANAGEMENT LLC 5% OR GREATER MORTGAGE INTEREST since 10/01/2020
THE SMITHERS MANAGEMENT TRUST 5% OR GREATER MORTGAGE INTEREST since 10/01/2020

Owner / manager individuals (11)

Name Role Association
REED, MICHAEL 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 12/12/2015
REED, STACIE 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 12/12/2015
THREADGILL, FORREST 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 10/01/2020
THREADGILL, MORGAN 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 10/01/2020
THREADGILL, SHARLYN 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 10/01/2020
SUTER, RACHEL OPERATIONAL/MANAGERIAL CONTROL since 06/27/2016
THREADGILL, SHARLYN OPERATIONAL/MANAGERIAL CONTROL since 10/01/2020
COMPTON, CHARLES 5% OR GREATER MORTGAGE INTEREST since 10/01/2020
COMPTON, JAMES 5% OR GREATER MORTGAGE INTEREST since 10/01/2020
COMPTON, KRIS 5% OR GREATER MORTGAGE INTEREST since 10/01/2020
MARTEL, MICHAEL 5% OR GREATER MORTGAGE INTEREST since 10/01/2020

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
None
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $49 metrics.cost_per_resident_day
Cost Report Current Ratio 3.68 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 59.7% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 12.4% metrics.medicare_day_share
Cost Report Net Income ($) $397,560 metrics.net_income
Cost Report Net Patient Revenue ($) $9,867,058 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 73.5% metrics.occupancy_rate
Cost Report Operating Margin (%) 3.3% metrics.operating_margin
Cost Report Total Assets ($) $2,132,214 metrics.total_assets
Cost Report Total Costs ($) $1,655,273 metrics.total_costs
Cost Report Total Fund Balances ($) $1,567,872 metrics.fund_balance
Cost Report Total Liabilities ($) $564,342 metrics.total_liabilities
Cost Report Total Margin (%) 4.0% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.09955 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.78724 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.15105 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.03784 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 2.79103 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 76.6 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.90965 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.47223 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.71700 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 4.09888 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.61273 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating — Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating — Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating — Chain Average QM Rating
Provider Information Chain Average Staffing Rating — Chain Average Staffing Rating
Provider Information Chain ID — Chain ID
Provider Information Chain Name — Chain Name
Provider Information City/Town Humble City/Town
Provider Information CMS Certification Number (CCN) 676412 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Harris County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2016-12-13 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 29.9355 Latitude
Provider Information Legal Business Name LTC OF FALL CREEK LLC Legal Business Name
Provider Information Location 14949 Mesa DR,Humble,TX,77396 Location
Provider Information Long-Stay QM Rating 2 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -95.269 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 126 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain — Number of Facilities in Chain
Provider Information Number of Fines 2 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.45205 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 1.05401 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 14949 Mesa DR Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name Fall Creek Rehabilitation and Healthcare Center Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 610 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 3 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 261 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 6 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 3 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-05-30 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 261 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 9 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 2 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2024-03-07 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 197 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 7 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 197 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 7 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.13773 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 60.0 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.32768 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 1.16732 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 1.89739 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.04329 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.16036 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.22507 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 3 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 1 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State TX State
Provider Information Telephone Number 2819024152 Telephone Number
Provider Information Total Amount of Fines in Dollars 48555.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 2.96304 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 2 Total Number of Penalties
Provider Information Total nursing staff turnover 74.2 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 245.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council None With a Resident and Family Council
Provider Information ZIP Code 77396 ZIP Code