Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fall Creek Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of aggressive behavior, including prior attempts to kick and past altercations with a former roommate, repeatedly struck another wheelchair-bound resident on the leg and foot during encounters in common areas when staff were not present. The aggressive resident’s care plan identified unwanted behaviors such as hitting others, but no new behavioral interventions had been added for nearly a year despite earlier incidents. Multiple residents and the Ombudsman reported that the aggressor became enraged when seeing the same peer, that there had been several prior episodes including hair-pulling, and that the targeted resident felt belittled, unprotected, and at times fearful. This pattern of known behavioral risk, prior altercations between the same two residents, and lack of timely, updated interventions to prevent further contact and abuse resulted in a failure to ensure residents’ right to be free from physical abuse.
A resident with severe cognitive impairment and a history of aggressive behavior had multiple documented episodes of physical aggression toward another cognitively intact, wheelchair-dependent resident, including attempts to kick and striking the other resident’s leg and foot on several occasions witnessed by peers and reported by the ombudsman. Despite these repeated incidents and a facility policy requiring the interdisciplinary team to review and revise comprehensive care plans after assessments, the behavior care plan for this resident had not been updated with new interventions since the prior year. The DON acknowledged responsibility for updating care plans and admitted forgetting to add interventions related to the more recent altercations, resulting in a cited deficiency for failing to review and revise the comprehensive care plan to address ongoing resident-to-resident aggression.
Two residents did not have comprehensive care plans reflecting their complex medical needs, including omission of a ventriculoperitoneal shunt for one and oxygen therapy for another. Staff interviews revealed inconsistent processes and unclear responsibility for updating care plans with new diagnoses and orders, resulting in incomplete documentation of essential care interventions.
Two residents with moderate cognitive impairment and significant physical needs did not receive or have documented assistance with bathing and personal hygiene as required by their care plans. Gaps in documentation and reports from family members indicated that necessary care was not consistently provided, and staff interviews confirmed issues with both the provision and recording of these services.
A resident with a recent ileostomy and complex medical history experienced persistent leakage, skin breakdown, and worsening symptoms due to staff's inability to maintain the ostomy system. Despite repeated issues and visible decline, nursing staff did not promptly notify the physician or obtain new orders, resulting in the resident being left in soiled conditions and ultimately requiring hospitalization for sepsis and acute kidney injury.
A resident with a recent ileostomy and complex medical history experienced repeated leakage and overfilling of the ostomy bag, with staff failing to maintain the wafer and bag in place or provide timely care. The resident was left in vomit and feces for extended periods, leading to skin breakdown and infection. Staff documented ongoing difficulties with ostomy management, and family members reported delays and poor customer service. The resident was hospitalized with sepsis and AKI, with hospital records linking these conditions to inadequate ostomy care and fecal contamination.
A resident with a recent ileostomy experienced repeated leakage and was left soiled for extended periods due to staff not emptying the ostomy bag in a timely manner and struggling to maintain the appliance. Staff interactions were unprofessional, with debates and dismissive comments made in front of the resident and family. The resident's physician was not promptly notified of significant changes, and the resident was sent to the hospital while still soiled. Additionally, staff failed to knock or announce themselves before entering the shared room of two other residents, compromising their dignity.
A resident with Alzheimer's/Dementia and a history of falls did not have a comprehensive care plan addressing fall risks, leading to multiple unwitnessed falls and serious injuries. The facility failed to implement effective fall prevention measures, and staff were not consistently informed of the resident's fall risk status. Observations showed that fall prevention measures were not in place, and there was inadequate staff supervision and communication.
A resident with Alzheimer's/Dementia and a history of falls experienced multiple unwitnessed falls resulting in serious injuries due to inadequate supervision and failure to update the care plan. The facility did not implement necessary fall prevention measures, such as frequent rounds or visual indicators of fall risk, leading to significant harm.
Failure to Protect Resident From Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse, specifically failing to prevent one cognitively impaired resident from physically striking another resident on multiple occasions. Resident #1, a female with hemiplegia/hemiparesis, dementia, mood disorder, bipolar disorder, psychotic disorder with hallucinations, and depression, had a care plan identifying unwanted behaviors including aggressive behavior such as hitting others and throwing a roommate’s clothes on the floor. Her quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment, and she was dependent on staff for ADLs. Despite a prior incident documented on 9/6/25 in which Resident #1 attempted to kick another resident while blocking a doorway and yelling, with another resident intervening to stop contact, no new behavioral interventions were added to her care plan after 3/10/25. On 3/16/26, an incident occurred in the activities room in which Resident #1 physically struck Resident #2. An incident report and nursing note by LVN C documented that Resident #1 approached another resident in the activities room and struck the other resident’s left leg several times, after which Resident #1 rolled herself into the dining room. Resident #2, a female with a history of cerebral infarction, hemiplegia/hemiparesis, contractures, stiffness, anxiety, and intact cognition (BIMS 15/15), was dependent on staff for ADLs and used an electric wheelchair with bilateral leg rests and boots. In her nursing note, LVN C recorded that Resident #2 identified her left leg as the area struck about five times, and a skin assessment revealed no redness, bruising, or pain, with Resident #2 initially denying emotional distress. The facility sent Resident #1 to the hospital for evaluation of aggression, and the ED documentation noted that staff reported Resident #1 was physically aggressive specifically toward one particular resident at the facility and not aggressive in other situations. Multiple interviews indicated that the altercations between Resident #1 and Resident #2 were not isolated to a single event. Resident #2 reported that Resident #1 attacked her “on sight” and that this had occurred three to four times, with the most recent event involving Resident #1 pounding on her left foot in the activities room when no staff were present. She stated she had previously been roommates with Resident #1, who had thrown her items on the floor, and that they had prior altercations. Resident #2 described feeling small, belittled, ignored, and unprotected, and later stated she was fearful of Resident #1 because she did not understand what triggered the aggression, although she also reported that the resident had not physically injured her. Other residents corroborated a pattern of aggression: Resident #3 stated she witnessed Resident #1 hit Resident #2 on the foot in the activities room a couple of weeks earlier and had to hold Resident #1’s hand until staff arrived, and Resident #4 reported that Resident #1 hit Resident #2 and became enraged when she saw her, with incidents occurring twice in the activity room and once outside. Additional information from the Ombudsman and staff further described an ongoing problematic relationship between the two residents. The Ombudsman stated that Resident #1 and Resident #2 did not have a good relationship, that Resident #2 had reported not feeling safe when Resident #1 was around, and that there had been an altercation a few weeks prior and a hair-pulling incident the previous year. The Ombudsman indicated that a care plan meeting was needed to determine why Resident #1 had so much anger toward Resident #2 and that the facility had not followed up on this request. The DON acknowledged that Resident #1 and Resident #2 had an incident about a year earlier and that Resident #2 sometimes sat near Resident #1 and made eye gestures that others interpreted negatively. The Administrator stated that, during his tenure, this was the first incident between the two residents that he was aware of, but also referenced differing accounts of the 3/16/26 event (kicking and/or slapping) and questioned the reliability of witnesses who were friends of Resident #2. Overall, the documented history of prior altercations, the known behavioral issues and severe cognitive impairment of Resident #1, the lack of updated behavioral interventions in Resident #1’s care plan after earlier incidents, and the repeated reports from residents and the Ombudsman that Resident #2 did not feel safe around Resident #1 led to the finding that the facility failed to protect residents’ right to be free from physical abuse.
Failure to Revise Care Plan After Repeated Resident-to-Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team reviewed and revised a resident’s comprehensive care plan after assessments and after new behavioral incidents, as required by facility policy. One resident with dementia, mood disorder, bipolar disorder, psychotic disorder with hallucinations, depression, and hemiplegia/hemiparesis had a care plan problem for unwanted behaviors, including aggressive behavior and hitting others, with interventions last added in early March of the prior year. The care plan, last reviewed in early March of the current year, contained behavior-related interventions such as administering medications, monitoring for side effects, providing 1:1 assistance as needed, notifying hospice, and room relocation, but no new interventions for unwanted behaviors had been added since March of the prior year despite subsequent incidents. Record review showed multiple resident-to-resident altercations involving this resident and another cognitively intact resident who was dependent for ADLs and used a wheelchair. An incident report from early September of the prior year documented that the resident attempted to kick another resident who was trying to move a wheelchair away from a doorway; the kick did not make contact because the other resident grabbed her leg. Another incident report from mid-March of the current year documented that the same resident approached another resident in the activities room and struck the other resident’s leg several times. Nursing notes from that date described that the incident was reported by the activities director and other residents, that the aggressive resident rolled into the dining room afterward, and that the other resident identified her left leg as the area struck about five times, though no redness, bruising, or pain were noted on assessment. Additional interviews and documentation confirmed a pattern of physical aggression by the resident toward the same other resident. The cognitively intact resident reported that the aggressive resident attacked her on sight, stating this had occurred three to four times, including pounding on her left foot in the activities room when no staff were present. Another resident witness stated that the aggressive resident hit the other resident on the foot and that he had seen similar incidents multiple times in the activity room and once outside. The facility ombudsman reported that the two residents did not have a good relationship, that the aggressive resident had previously pulled the other resident’s hair, and that a care plan meeting was needed to determine why the aggressive resident became angry when seeing the other resident, but the facility had not followed up on this care plan meeting request. The DON acknowledged responsibility for updating care plans, stated she did not know what else to add because behaviors were already care planned indefinitely, and admitted she forgot to add new interventions related to the more recent incidents, despite facility policy requiring the comprehensive care plan to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The medical record from the hospital visit on the date of the March incident documented that facility staff reported the resident was sent for evaluation of aggression and that she was physically aggressive only toward one particular resident and not in other situations. The ED provider noted that the resident was not aggressive during the hospital evaluation and characterized the situation as an interpersonal issue between the two residents. Multiple interviews with staff, residents, and the ombudsman consistently described repeated episodes of physical aggression by the same resident toward the same peer, while the written care plan for behaviors remained unchanged since the prior year and did not incorporate specific, updated interventions addressing these recurrent resident-to-resident altercations. This lack of timely review and revision of the care plan after new behavioral incidents formed the basis of the cited deficiency. Facility policy on comprehensive care plans, revised in January of the current year, required development and implementation of a person-centered care plan that includes measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The policy specified that the comprehensive care plan must be developed within seven days after completion of the comprehensive MDS assessment, must describe services to attain or maintain the resident’s highest practicable well-being, and must include resident-specific interventions reflecting needs and preferences. It further required that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Despite these requirements and the documented pattern of resident-to-resident aggression, the resident’s behavior care plan was not updated with new or revised interventions following the September and March incidents, leading to the cited failure to ensure the interdisciplinary team reviewed and revised the care plan after each assessment and behavioral event.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Medical Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one resident with a history of dementia, end stage renal disease, hydrocephalus, and a ventriculoperitoneal shunt, the care plan did not include any information regarding the presence of the shunt. Despite documentation in medical records and hospital discharge instructions about the shunt and its associated risks, the care plan only addressed neurological status related to hydrocephalus and seizures, omitting specific interventions or monitoring related to the shunt. For another resident with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, the care plan did not initially include information about the use of oxygen therapy, despite active orders for continuous oxygen via nasal cannula. The omission was confirmed through record review and staff interviews, which revealed inconsistent understanding among staff regarding responsibility for updating care plans with new orders or diagnoses. Interviews with facility staff, including the DON, MDS nurse, ADON, and unit manager, demonstrated a lack of clarity and consistency in the process for updating care plans to reflect new or ongoing medical needs. Staff acknowledged that without accurate and complete care plans, essential information about residents' conditions and required interventions might not be communicated to all caregivers, potentially impacting care delivery.
Failure to Provide and Document Assistance with Bathing and Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing and personal hygiene, to two residents who were unable to perform these tasks independently. Both residents had moderate cognitive impairment and required substantial or maximal assistance with bathing, as documented in their care plans and Minimum Data Set (MDS) assessments. Despite these documented needs, there was a lack of recorded evidence that bathing was provided during specific periods of their stays, and no documentation was found indicating that the residents refused or were unavailable for bathing during those times. For one resident, there was no documentation of bathing from admission through a week-long period, and for the other, no bathing documentation was found during the initial days of admission or for a week following a hospital readmission, except for one documented refusal. Progress notes did not contain any information about bathing or refusals during these gaps. Family members of both residents reported concerns about the residents' hygiene, with one family member stating the resident was consistently unclean and expressing distress over the lack of care provided. Interviews with facility staff, including the DON, ADON, and Unit Manager, confirmed that the only place for documenting bathing was the electronic medical record and that there had been issues with staff not documenting showers properly. Staff described the process for handling refusals and oversight responsibilities, but acknowledged that documentation and monitoring practices had only recently been updated. The facility's policy required necessary services for residents unable to perform ADLs, but the records and interviews indicated these services were not consistently provided or documented for the two residents in question.
Failure to Notify Physician of Significant Change in Condition Resulting in Resident Harm
Penalty
Summary
The facility failed to immediately inform and consult with a resident's physician regarding significant changes in the resident's condition, specifically related to the management of an ileostomy. Nursing staff experienced ongoing difficulties maintaining the integrity of the resident's ileostomy system, resulting in frequent leakage, skin breakdown, and an inability to keep the wafer and bag securely attached. Despite repeated unsuccessful attempts to manage the situation using various interventions such as ostomy paste, skin prep, and powder, the severity of the resident's condition and the lack of improvement were not promptly communicated to the nurse practitioner or physician. Documentation and interviews revealed that the staff did not obtain new physician orders in response to the resident's deteriorating skin condition and persistent issues with the ostomy system. The resident, who had a complex medical history including Crohn's disease, severe protein-calorie malnutrition, and a recent ileostomy creation, experienced a rapid decline. The resident suffered from nausea, vomiting, abdominal pain, and bowel movements from the rectum despite the presence of an ileostomy. Staff and family interviews indicated that the resident was left in soiled conditions for extended periods, and there was a lack of timely and effective communication with the medical provider regarding the resident's worsening symptoms and the inability to manage the ostomy care. The resident was eventually transferred to the hospital, where he was diagnosed with sepsis and acute kidney injury, conditions attributed in part to the inadequate management and delayed medical intervention at the facility. Observations and interviews with staff, family members, and the resident himself confirmed that the facility's failure to notify and consult with the physician about the severity and persistence of the resident's condition led to a delay in appropriate medical treatment. The resident was found covered in vomit and feces at the time of transfer, and staff admitted to being unprepared and inadequately trained to manage the resident's complex care needs. The deficiency was identified as Immediate Jeopardy, as the lack of timely physician notification and intervention resulted in a significant decline in the resident's health and required hospitalization.
Failure to Provide Timely and Effective Ileostomy Care Resulting in Hospitalization
Penalty
Summary
The facility failed to provide appropriate ileostomy care and services for a resident who required such care, resulting in significant adverse outcomes. The resident, who had a complex medical history including Crohn's disease, severe malnutrition, schizophrenia, and recent ileostomy creation, was observed and reported to have repeated issues with the ileostomy wafer and bag not remaining in place. Staff documented and family members reported frequent leakage, overfilling, and delays in emptying and changing the ileostomy bag, leading to the resident being left in vomit and feces for extended periods. Photographic evidence and interviews confirmed that the resident was found covered in bodily waste, with towels and briefs used as makeshift measures to manage leakage, and the ostomy site left uncovered at times to allow the skin to dry. Multiple staff members, including LVNs and CNAs, described ongoing difficulties maintaining the ostomy system due to high output and poor wafer adhesion, with interventions such as using adhesive pastes, skin prep, and absorbent materials proving ineffective. Despite these challenges, the resident's care plan and physician orders required regular and as-needed ostomy care, including timely emptying and changing of the bag and wafer. Documentation and interviews revealed that staff became frustrated with the resident's needs, and there were delays and reluctance in providing necessary care, as well as poor communication and customer service. Family members repeatedly raised concerns about the resident being left in soiled conditions and the lack of prompt response from staff. As a result of these failures, the resident developed excoriation and skin breakdown around the stoma, experienced nausea, vomiting, and abdominal pain, and was ultimately transferred to the hospital. Upon hospital admission, the resident was diagnosed with sepsis, acute kidney injury (AKI), and abdominal wall cellulitis, with medical records and hospital staff attributing these conditions to inadequate ostomy maintenance and fecal contamination. The incident was identified as Immediate Jeopardy, and the facility's deficient practices placed not only this resident but also others with ostomies at risk for serious harm.
Failure to Provide Dignified and Timely Ostomy Care, and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide care that maintained the dignity and quality of life for several residents, particularly a male resident with a recent ileostomy. Despite clear orders for regular ostomy care, staff did not consistently empty the resident's ileostomy bag in a timely manner, resulting in repeated leakage of bowel contents onto the resident and his bedding. On multiple occasions, the resident was left soiled for extended periods, and staff struggled to keep the ostomy system intact, with some resorting to using towels and briefs to absorb leakage rather than promptly replacing the ostomy appliance. Documentation and interviews confirm that the resident was found with a full, leaking ileostomy bag on several shifts, and family members had to repeatedly request staff intervention. Staff interactions with the resident and his family were unprofessional and lacked respect. Interviews revealed that a nurse and a CNA debated in front of the resident and his family about who would provide care, and the nurse made dismissive comments about having to "deal with" the resident. The resident and family reported that staff expressed disgust while providing care and accused the resident of causing the leakage, which he denied. The resident, who was cognitively intact, reported feeling neglected and stated that his call light was not answered promptly when he needed assistance with his ostomy care. Additionally, the facility failed to ensure that staff were adequately trained in ostomy care and did not promptly notify the resident's physician of significant changes in his condition, such as persistent leakage, vomiting, and the presence of bowel movements from the rectum despite the ileostomy. When the resident was eventually sent to the hospital, he was transported while still soiled with vomit and feces. The facility also failed to ensure that staff knocked and announced themselves before entering the shared room of two other residents, further compromising resident dignity.
Failure to Implement Comprehensive Fall Prevention Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as CR#1, who was at risk for falls. This deficiency was identified through observations, interviews, and record reviews, which revealed that the care plan did not include measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs. The resident, who had a history of Alzheimer's/Dementia, hypertension, and coronary artery disease, experienced multiple unwitnessed falls, some resulting in serious injuries, including a brain bleed and fractures. The resident's care plan, dated 11/13/24, included interventions for cognitive impairment and visual function but failed to adequately address the risk of falls. Despite having a history of falls, the care plan did not include specific, measurable interventions to prevent further incidents. The facility's failure to implement effective fall prevention measures placed the resident at risk of serious harm and injury. Interviews with staff revealed a lack of awareness and implementation of fall prevention protocols, such as the Falling Star Program, which would have alerted staff to the resident's fall risk. The deficiency was further compounded by inadequate staff supervision and communication. Interviews indicated that staff were not consistently informed of the resident's fall risk status, and there were no meetings to discuss interventions for the resident's falls. Observations of the resident's room showed that fall prevention measures, such as a low bed position and floor mats, were not in place. The facility's failure to ensure the resident received the necessary care and services to decrease the risk of falls resulted in multiple unwitnessed falls and serious injuries.
Failure to Prevent Falls in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions for a resident identified as a high fall risk, leading to multiple falls and serious injuries. The resident, who had a history of Alzheimer's/Dementia and other medical conditions, experienced several unwitnessed falls, including two falls within a short period on the same day, resulting in significant injuries such as a brain bleed and fractures. Despite being identified as a fall risk, the resident's care plan was not updated to reflect the increased risk, and preventive measures were not effectively implemented. Observations and interviews revealed that the resident's room lacked indicators of fall risk, such as stars on the door or bed, which are part of the facility's Fall Prevention Program. Staff interviews indicated a lack of awareness regarding the resident's fall risk status and the necessary interventions required. The resident's care plan did not include more frequent rounds or other specific measures to prevent falls, and there was a failure to communicate and implement these interventions among the staff. The facility's failure to update the care plan and implement effective fall prevention measures placed the resident at risk of serious harm. The resident's repeated falls and subsequent injuries highlight the inadequacy of the facility's response to the resident's needs and the lack of timely and appropriate interventions to prevent further incidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Humble
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakmont Healthcare And Rehabilitation Of Humble | 3.1 mi | ★★★★★ | 16 | 0 |
| Focused Care At Humble | 4 mi | ★★★★★ | 1 | 0 |
| Park Manor Of Humble | 4.3 mi | ★★★★★ | 9 | 0 |
| Crimson Heights Health & Wellness | 4.5 mi | ★★★★★ | 15 | 0 |
| Deerbrook Skilled Nursing And Rehab Center | 4.6 mi | ★★★★★ | 14 | 3 |
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