Skilled nursing facility · CMS certification number 676412
Fall Creek Rehabilitation and Healthcare Center
Humble, Texas · Medicare and Medicaid
Certified beds, as filed in Care Compare: 126
Download this facility’s record (CSV)
A CSV file of this facility’s record: its name and location, its Medicare cost-report finances year by year, its ownership, its inspections, deficiencies and penalties, and the Care Compare provider information — each figure with the worksheet, line and column or file it came from.
In Care Compare’s provider information: Penalties: 2 · Fines: 2 · Fines, total amount: $48,555.00 · Payment denials: 0. The most recent penalty on file: April 13, 2025, Fine, $33,683. Every penalty on file ↓
For this facility: the citable document with full history — $295 · an email when this record changes — $99/month
Finances, as filed
From this facility’s Medicare cost reports on form CMS-2540, each figure with the worksheet, line and column it was read from.
Cost report for January 1, 2024 to December 31, 2024 — a reporting period of 365 days, on form CMS-2540-10, settled, processed by CMS on May 6, 2026.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $12,263,379 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Contractual allowances and discounts | $1,903,088 | CMS-2540-10 worksheet G300000 line 200 column 100 |
| Net patient revenue | $10,360,291 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $9,876,413 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | $483,878 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | $34,152 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | $518,030 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: $518,030 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Bed days available, all components | 46,116 | CMS-2540-10 worksheet S300001 line 800 column 200 |
| Medicare (Title XVIII) patient days | 4,205 | CMS-2540-10 worksheet S300001 line 800 column 400 |
| Medicaid (Title XIX) patient days | 19,893 | CMS-2540-10 worksheet S300001 line 800 column 500 |
| Other-payer patient days | 9,691 | CMS-2540-10 worksheet S300001 line 800 column 600 |
| Total patient days, all components | 33,789 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Medicare discharges | 135 | CMS-2540-10 worksheet S300001 line 800 column 900 |
| Medicaid discharges | 69 | CMS-2540-10 worksheet S300001 line 800 column 1000 |
| Other-payer discharges | 371 | CMS-2540-10 worksheet S300001 line 800 column 1100 |
| Total discharges, all components | 575 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 31.15 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 288.3 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 58.76 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1449222, read from the public cost report file SNF10FY2024.zip.
Fiscal year 2023, ended December 31, 2023
Cost report for January 1, 2023 to December 31, 2023 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on January 16, 2025.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $11,886,450 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Contractual allowances and discounts | $2,019,392 | CMS-2540-10 worksheet G300000 line 200 column 100 |
| Net patient revenue | $9,867,058 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $9,543,969 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | $323,089 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | $74,471 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | $397,560 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: $397,560 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Total patient days, all components | 33,801 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Total discharges, all components | 570 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 29.26 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 330.67 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 59.3 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1402371, read from the public cost report file SNF10FY2023.zip.
Fiscal year 2022, ended December 31, 2022
Cost report for January 1, 2022 to December 31, 2022 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on February 23, 2024.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $11,193,858 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Contractual allowances and discounts | $2,247,438 | CMS-2540-10 worksheet G300000 line 200 column 100 |
| Net patient revenue | $8,946,420 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $8,741,553 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | $204,867 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | $306,598 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | $511,465 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: $511,465 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Total patient days, all components | 29,821 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Total discharges, all components | 441 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 33.97 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 242.41 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 67.62 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1373808, read from the public cost report file SNF10FY2022.zip.
Fiscal year 2021, ended December 31, 2021
Cost report for January 1, 2021 to December 31, 2021 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on August 16, 2023.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $10,951,616 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Contractual allowances and discounts | $2,692,988 | CMS-2540-10 worksheet G300000 line 200 column 100 |
| Net patient revenue | $8,258,628 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $8,482,333 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | −$223,705 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | $983,816 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | $760,111 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: $760,111 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Total patient days, all components | 29,329 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Total discharges, all components | 495 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 26.62 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 245.48 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 59.25 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1362370, read from the public cost report file SNF10FY2021.zip.
Fiscal year 2020, ended December 31, 2020
Cost report for January 1, 2020 to December 31, 2020 — a reporting period of 365 days, on form CMS-2540-10, settled, processed by CMS on December 29, 2022.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $15,414,505 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Contractual allowances and discounts | $6,398,986 | CMS-2540-10 worksheet G300000 line 200 column 100 |
| Net patient revenue | $9,015,519 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $9,571,609 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | −$556,090 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | $892,470 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | $336,380 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: $336,380 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Total patient days, all components | 31,575 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Total discharges, all components | 466 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 28.87 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 405.67 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 67.76 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1339259, read from the public cost report file SNF10FY2020.zip.
Fiscal year 2019, ended December 31, 2019
Cost report for January 1, 2019 to December 31, 2019 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on June 15, 2021.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $15,631,001 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Contractual allowances and discounts | $5,008,839 | CMS-2540-10 worksheet G300000 line 200 column 100 |
| Net patient revenue | $10,622,162 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $10,156,969 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | $465,193 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | −$2,337 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | $462,856 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: $401,051 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Total patient days, all components | 36,476 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Total discharges, all components | 499 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 35.06 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 277.94 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 73.1 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1286217, read from the public cost report file SNF10FY2019.zip.
Fiscal year 2018, ended December 31, 2018
Cost report for January 1, 2018 to December 31, 2018 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on February 25, 2020.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $15,175,884 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Contractual allowances and discounts | $4,037,540 | CMS-2540-10 worksheet G300000 line 200 column 100 |
| Net patient revenue | $11,138,344 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $9,971,652 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | $1,166,692 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | $3,073 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | $1,169,765 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: $1,169,765 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Total patient days, all components | 38,019 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Total discharges, all components | 567 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 31.75 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 275.59 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 67.05 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1251484, read from the public cost report file SNF10FY2018.zip.
Fiscal year 2017, ended December 31, 2017
Cost report for December 13, 2016 to December 31, 2017 — a reporting period of 383 days, on form CMS-2540-10, settled, processed by CMS on February 2, 2019.
| Figure | As filed | Where it comes from |
|---|---|---|
| Total patient revenue | $7,750,959 | CMS-2540-10 worksheet G300000 line 100 column 100 |
| Net patient revenue | $7,750,959 | CMS-2540-10 worksheet G300000 line 300 column 100 |
| Total operating expenses | $8,284,091 | CMS-2540-10 worksheet G300000 line 400 column 100 |
| Net income from service to patients | −$533,132 | CMS-2540-10 worksheet G300000 line 500 column 100 |
| Total other income | $3,175 | CMS-2540-10 worksheet G300000 line 2500 column 100 |
| Net income after other income | −$529,957 | CMS-2540-10 worksheet G300000 line 2600 column 100 |
Net income: −$529,957 (CMS-2540-10 worksheet G300000 line 3100 column 100). As filed, net income for the period equals net income from service to patients plus total other income, less total other expenses (Worksheet G-3 lines 26 less 27 through 30) on 204,151 of the 204,151 reports filed on Form CMS-2540-10 in publication years 2011-2025 that file every line it is computed from (100%).
| Figure | As filed | Where it comes from |
|---|---|---|
| Total facility beds, all components | 126 | CMS-2540-10 worksheet S300001 line 800 column 100 |
| Total patient days, all components | 28,069 | CMS-2540-10 worksheet S300001 line 800 column 700 |
| Total discharges, all components | 414 | CMS-2540-10 worksheet S300001 line 800 column 1200 |
| Average length of stay, Medicare, in days | 32.9 | CMS-2540-10 worksheet S300001 line 800 column 1400 |
| Average length of stay, Medicaid, in days | 305.38 | CMS-2540-10 worksheet S300001 line 800 column 1500 |
| Average length of stay, all patients, in days | 67.8 | CMS-2540-10 worksheet S300001 line 800 column 1600 |
CMS report record 1218914, read from the public cost report file SNF10FY2017.zip.
Nurse staffing
Nurse staffing hours from the Payroll-Based Journal, quarter by quarter, are on this facility’s staffing page, each quarter with the file it came from.
Ownership, as filed with CMS
Care Compare
As filed (Care Compare ownership).
| Owner or manager | Role | Type | Ownership percentage | Association |
|---|---|---|---|---|
| BULLPEN ONE, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 10% | since 12/12/2015 |
| EDAWS INVESTMENT GROUP, LP | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 90% | since 12/12/2015 |
| BULLPEN FAMILY VENTURE, LP | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | since 12/12/2015 |
| REED, MICHAEL | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | since 12/12/2015 |
| REED, STACIE | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | since 12/12/2015 |
| THREADGILL, FORREST | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | since 10/01/2020 |
| THREADGILL, MORGAN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | since 10/01/2020 |
| THREADGILL, SHARLYN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | since 10/01/2020 |
| CLEARLAKE HEALTHCARE REALTY, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | since 10/01/2020 |
| COMPTON, CHARLES | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | since 10/01/2020 |
| COMPTON, JAMES | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | since 10/01/2020 |
| COMPTON, KRIS | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | since 10/01/2020 |
| COMPTON3 HOLDINGS, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | since 10/01/2020 |
| MARTEL HEALTHCARE MANAGEMENT LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | since 10/01/2020 |
| MARTEL, MICHAEL | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | since 10/01/2020 |
| THE SMITHERS MANAGEMENT TRUST | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | since 10/01/2020 |
| CLEARLAKE HEALTHCARE REALTY, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | since 10/01/2020 |
| COMPTON, CHARLES | ADP OF THE SNF | Individual | NOT APPLICABLE | since 10/01/2020 |
| COMPTON, JAMES | ADP OF THE SNF | Individual | NOT APPLICABLE | since 10/01/2020 |
| COMPTON, KRIS | ADP OF THE SNF | Individual | NOT APPLICABLE | since 10/01/2020 |
| COMPTON3 HOLDINGS, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | since 10/01/2020 |
| LANIER, JULIA | ADP OF THE SNF | Individual | NOT APPLICABLE | since 06/12/2018 |
| MARTEL HEALTHCARE MANAGEMENT LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | since 10/01/2020 |
| MARTEL, MICHAEL | ADP OF THE SNF | Individual | NOT APPLICABLE | since 10/01/2020 |
| SUTER, RACHEL | ADP OF THE SNF | Individual | NOT APPLICABLE | since 06/27/2016 |
| THE SMITHERS MANAGEMENT TRUST | ADP OF THE SNF | Organization | NOT APPLICABLE | since 10/01/2020 |
| SMITHERS, JEFFREY | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | since 03/28/2025 |
| SUTER, RACHEL | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | since 06/27/2016 |
| THREADGILL, SHARLYN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | since 10/01/2020 |
Medicare enrollment
As filed (Medicare enrollment ownership), under the enrollment of LTC OF FALL CREEK LLC (enrollment ID O20161003000511).
CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; where the private equity, real estate investment trust or holding company field below has not been filed under the current cycle, it reads “Paused by CMS”.
| Owner | Individual or organization | Role | Ownership percentage | Association date | Described in the filing as |
|---|---|---|---|---|---|
| BULLPEN ONE, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10.00 | 12/12/2015 | Private equity company: No Real estate investment trust: No Holding company: No |
| EDAWS INVESTMENT GROUP, LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 90.00 | 12/12/2015 | Private equity company: No Real estate investment trust: No Holding company: No |
| BULLPEN FAMILY VENTURE, LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100.00 | 12/12/2015 | Private equity company: No Real estate investment trust: No Holding company: No |
| FORREST THREADGILL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10.00 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| MICHAEL G REED | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50.00 | 12/12/2015 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| MORGAN THREADGILL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10.00 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| SHARLYN THREADGILL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 78.00 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| STACIE W REED | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50.00 | 12/12/2015 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| CHARLES COMPTON | Individual | 5% OR GREATER MORTGAGE INTEREST | 8.33 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| CLEARLAKE HEALTHCARE REALTY, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | 100.00 | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| COMPTON3 HOLDINGS, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | 33.33 | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| JAMES COMPTON | Individual | 5% OR GREATER MORTGAGE INTEREST | 8.33 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| JAMES COMPTON | Individual | 5% OR GREATER MORTGAGE INTEREST | 8.33 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| KRIS COMPTON | Individual | 5% OR GREATER MORTGAGE INTEREST | 8.33 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| MARTEL HEALTHCARE MANAGEMENT LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | 33.33 | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| MICHAEL MARTEL | Individual | 5% OR GREATER MORTGAGE INTEREST | 33.33 | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| THE SMITHERS MANAGEMENT TRUST | Organization | 5% OR GREATER MORTGAGE INTEREST | 33.34 | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| CHARLES COMPTON | Individual | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| CLEARLAKE HEALTHCARE REALTY, LLC | Organization | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| COMPTON3 HOLDINGS, LLC | Organization | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| JAMES COMPTON | Individual | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| JAMES COMPTON | Individual | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| JULIA LANIER | Individual | ADP OF THE SNF | Not stated in the filing | 06/12/2018 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| KRIS COMPTON | Individual | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| MARTEL HEALTHCARE MANAGEMENT LLC | Organization | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| MICHAEL MARTEL | Individual | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| RACHEL M SUTER | Individual | ADP OF THE SNF | Not stated in the filing | 06/27/2016 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| THE SMITHERS MANAGEMENT TRUST | Organization | ADP OF THE SNF | Not stated in the filing | 10/01/2020 | Private equity company: No Real estate investment trust: No Holding company: No |
| RACHEL M SUTER | Individual | OPERATIONAL/MANAGERIAL CONTROL | Not stated in the filing | 06/27/2016 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
| SHARLYN THREADGILL | Individual | OPERATIONAL/MANAGERIAL CONTROL | Not stated in the filing | 10/01/2020 | Private equity company: Paused by CMS Real estate investment trust: Paused by CMS Holding company: Paused by CMS |
Changes in ownership
- June 1, 2025: JULIA LANIER no longer appears as W-2 MANAGING EMPLOYEE in the Medicare enrollment ownership file. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: SHARLYN THREADGILL no longer appears as CORPORATE OFFICER in the Medicare enrollment ownership file. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: LTC HOUSTON MANAGEMENT LLC no longer appears as OPERATIONAL/MANAGERIAL CONTROL in the Medicare enrollment ownership file. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MICHAEL MARTEL (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MICHAEL MARTEL (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: JULIA LANIER (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since June 12, 2018. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: SHARLYN THREADGILL (OPERATIONAL/MANAGERIAL CONTROL) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: RACHEL M SUTER (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since June 27, 2016. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: RACHEL M SUTER (OPERATIONAL/MANAGERIAL CONTROL) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since June 27, 2016. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CLEARLAKE HEALTHCARE REALTY, LLC (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CLEARLAKE HEALTHCARE REALTY, LLC (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CHARLES COMPTON (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CHARLES COMPTON (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: KRIS COMPTON (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: KRIS COMPTON (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: COMPTON3 HOLDINGS, LLC (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: COMPTON3 HOLDINGS, LLC (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: THE SMITHERS MANAGEMENT TRUST (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: THE SMITHERS MANAGEMENT TRUST (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: BULLPEN FAMILY VENTURE, LP (5% OR GREATER INDIRECT OWNERSHIP INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since December 12, 2015. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MARTEL HEALTHCARE MANAGEMENT LLC (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MARTEL HEALTHCARE MANAGEMENT LLC (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: JAMES COMPTON (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: JAMES COMPTON (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
Recent changes on this record
- July 26, 2026: A deficiency was cited under tag F 0677, scope and severity E. NH_HealthCitations_Sep2026_2.csv
- July 17, 2026: A deficiency was cited under tag F 0919, scope and severity D. NH_HealthCitations_Oct2026.csv
- July 17, 2026: A deficiency was cited under tag F 0812, scope and severity D. NH_HealthCitations_Oct2026.csv
- July 17, 2026: A deficiency was cited under tag F 0693, scope and severity D. NH_HealthCitations_Oct2026.csv
- July 17, 2026: A deficiency was cited under tag F 0755, scope and severity E. NH_HealthCitations_Oct2026.csv
- July 17, 2026: A deficiency was cited under tag F 0677, scope and severity E. NH_HealthCitations_Oct2026.csv
- July 17, 2026: An inspection was recorded in inspection cycle 1. NH_SurveySummary_Oct2026.csv
- July 17, 2026: A deficiency was cited under tag F 0656, scope and severity D. NH_HealthCitations_Sep2026_2.csv
- May 6, 2026: A cost report was filed for fiscal year 2024, on form CMS-2540-10. SNF10FY2024.zip
- June 1, 2025: JULIA LANIER no longer appears as W-2 MANAGING EMPLOYEE in the Medicare enrollment ownership file. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: SHARLYN THREADGILL no longer appears as CORPORATE OFFICER in the Medicare enrollment ownership file. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: LTC HOUSTON MANAGEMENT LLC no longer appears as OPERATIONAL/MANAGERIAL CONTROL in the Medicare enrollment ownership file. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MICHAEL MARTEL (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MICHAEL MARTEL (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: JULIA LANIER (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since June 12, 2018. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: SHARLYN THREADGILL (OPERATIONAL/MANAGERIAL CONTROL) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: RACHEL M SUTER (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since June 27, 2016. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: RACHEL M SUTER (OPERATIONAL/MANAGERIAL CONTROL) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since June 27, 2016. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CLEARLAKE HEALTHCARE REALTY, LLC (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CLEARLAKE HEALTHCARE REALTY, LLC (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CHARLES COMPTON (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: CHARLES COMPTON (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: KRIS COMPTON (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: KRIS COMPTON (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: COMPTON3 HOLDINGS, LLC (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: COMPTON3 HOLDINGS, LLC (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: THE SMITHERS MANAGEMENT TRUST (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: THE SMITHERS MANAGEMENT TRUST (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: BULLPEN FAMILY VENTURE, LP (5% OR GREATER INDIRECT OWNERSHIP INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since December 12, 2015. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MARTEL HEALTHCARE MANAGEMENT LLC (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: MARTEL HEALTHCARE MANAGEMENT LLC (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: JAMES COMPTON (ADP OF THE SNF) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- June 1, 2025: JAMES COMPTON (5% OR GREATER MORTGAGE INTEREST) first listed in CMS’s Medicare enrollment ownership file on June 1, 2025; associated with this enrollment since October 1, 2020. Skilled_Nursing_Facility_All_Owners_:_2025-06-01.csv
- January 16, 2025: A cost report was filed for fiscal year 2023, on form CMS-2540-10. SNF10FY2023.zip
- February 23, 2024: A cost report was filed for fiscal year 2022, on form CMS-2540-10. SNF10FY2022.zip
- August 16, 2023: A cost report was filed for fiscal year 2021, on form CMS-2540-10. SNF10FY2021.zip
- December 29, 2022: A cost report was filed for fiscal year 2020, on form CMS-2540-10. SNF10FY2020.zip
- June 15, 2021: A cost report was filed for fiscal year 2019, on form CMS-2540-10. SNF10FY2019.zip
- February 25, 2020: A cost report was filed for fiscal year 2018, on form CMS-2540-10. SNF10FY2018.zip
- February 2, 2019: A cost report was filed for fiscal year 2017, on form CMS-2540-10. SNF10FY2017.zip
Inspections
| Inspection cycle | Health inspection | Fire safety inspection | Health deficiencies | Fire safety deficiencies |
|---|---|---|---|---|
| 1 | July 17, 2026 | July 17, 2026 | 10 | 1 |
| 2 | May 30, 2025 | May 30, 2025 | 11 | 2 |
| 3 | March 7, 2024 | March 7, 2024 | 5 | 2 |
| 3 | December 8, 2022 | December 8, 2022 | 6 | 1 |
From the Care Compare inspection summary file NH_SurveySummary_Oct2026.csv, processed on October 1, 2026.
Deficiencies cited
29 deficiencies on file, newest inspection first
| Inspection date | Inspection type | Tag | Category | What was cited | Scope and severity | Complaint | Corrected | Correction date |
|---|---|---|---|---|---|---|---|---|
| July 26, 2026 | Health | F 0677 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Yes | Deficient, Provider has no plan of correction | |
| July 17, 2026 | Health | F 0656 | 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. | D | Yes | Deficient, Provider has date of correction | July 20, 2026 |
| July 17, 2026 | Health | F 0677 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | No | Deficient, Provider has date of correction | July 20, 2026 |
| July 17, 2026 | Health | F 0693 | Quality of Life and Care Deficiencies | 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. | D | No | Deficient, Provider has date of correction | July 20, 2026 |
| July 17, 2026 | Health | F 0755 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | No | Deficient, Provider has date of correction | July 20, 2026 |
| July 17, 2026 | Health | F 0812 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | No | Deficient, Provider has date of correction | July 20, 2026 |
| July 17, 2026 | Health | F 0919 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | No | Deficient, Provider has date of correction | July 20, 2026 |
| June 16, 2026 | Health | F 0559 | 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. | D | Yes | Deficient, Provider has date of correction | July 16, 2026 |
| April 1, 2026 | Health | F 0600 | 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. | D | Yes | Deficient, Provider has date of correction | April 3, 2026 |
| April 1, 2026 | Health | F 0657 | 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. | D | Yes | Deficient, Provider has date of correction | April 3, 2026 |
| July 8, 2025 | Health | F 0880 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E | Yes | Deficient, Provider has date of correction | July 14, 2025 |
| May 30, 2025 | Health | F 0583 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D | No | Deficient, Provider has date of correction | June 2, 2025 |
| May 30, 2025 | Health | F 0656 | 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. | D | Yes | Deficient, Provider has date of correction | June 2, 2025 |
| May 30, 2025 | Health | F 0677 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Yes | Deficient, Provider has date of correction | June 2, 2025 |
| May 30, 2025 | Health | F 0695 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D | No | Deficient, Provider has date of correction | June 2, 2025 |
| May 30, 2025 | Health | F 0759 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D | No | Deficient, Provider has date of correction | June 2, 2025 |
| April 13, 2025 | Health | F 0550 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Yes | Deficient, Provider has date of correction | April 14, 2025 |
| April 13, 2025 | Health | F 0580 | 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. | K | Yes | Deficient, Provider has date of correction | April 14, 2025 |
| April 13, 2025 | Health | F 0691 | Quality of Life and Care Deficiencies | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | K | Yes | Deficient, Provider has date of correction | April 14, 2025 |
| February 5, 2025 | Health | F 0656 | 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. | J | Yes | Deficient, Provider has date of correction | February 6, 2025 |
| February 5, 2025 | Health | F 0689 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Yes | Deficient, Provider has date of correction | February 6, 2025 |
| March 13, 2024 | Health | F 0600 | 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. | K | Yes | Past Non-Compliance | February 15, 2024 |
| March 13, 2024 | Health | F 0602 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | K | Yes | Past Non-Compliance | November 21, 2023 |
| March 13, 2024 | Health | F 0761 | 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. | K | Yes | Past Non-Compliance | November 21, 2023 |
| March 7, 2024 | Health | F 0656 | 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. | D | Yes | Deficient, Provider has date of correction | April 3, 2024 |
| March 7, 2024 | Health | F 0692 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | E | Yes | Deficient, Provider has date of correction | April 3, 2024 |
| December 8, 2022 | Health | F 0755 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | No | Deficient, Provider has date of correction | December 14, 2022 |
| December 8, 2022 | Health | F 0761 | 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. | E | No | Deficient, Provider has date of correction | December 14, 2022 |
| December 8, 2022 | Health | F 0814 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | C | No | Deficient, Provider has date of correction | December 14, 2022 |
From the Care Compare health citations file NH_HealthCitations_Oct2026.csv, processed on October 1, 2026.
Penalties
| Penalty date | Type | Fine amount | Payment denial began | Payment denial, days | Fine ID |
|---|---|---|---|---|---|
| April 13, 2025 | Fine | $33,683 | 113775 | ||
| February 5, 2025 | Fine | $14,872 | 113569 |
From the Care Compare penalties file NH_Penalties_Oct2026.csv, processed on October 1, 2026.
Care Compare provider information
| Field | As filed |
|---|---|
| Provider Type | Medicare and Medicaid |
| Ownership Type | For profit - Limited Liability company |
| Legal Business Name | LTC OF FALL CREEK LLC |
| Date First Approved to Provide Medicare and Medicaid Services | 2016-12-13 |
| Provider Resides in Hospital | N |
| Continuing Care Retirement Community | N |
| Urban | Y |
| County/Parish | Harris |
| Telephone Number | 2819024152 |
| Provider Changed Ownership in Last 12 Months | N |
| With a Resident and Family Council | Resident |
| Automatic Sprinkler Systems in All Required Areas | Yes |
| Number of Certified Beds | 126 |
| Average Number of Residents per Day | 84.9 |
| Overall Rating | 1 |
| Health Inspection Rating | 1 |
| QM Rating | 3 |
| Long-Stay QM Rating | 4 |
| Short-Stay QM Rating | 3 |
| Processing Date | 2026-10-01 |
From the Care Compare Provider Information file NH_ProviderInfo_Oct2026.csv, processed on October 1, 2026.
Get an email when this record changes
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On July 26, 2026: A deficiency was cited under tag F 0677, scope and severity E. That is one line of the alert.
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The citable document for Fall Creek Rehabilitation and Healthcare Center
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