Cypress Creek Rehabilitation and Healthcare Center
13600 Birdcall Lane, Cypress, TX 77429 · CCN 676467
Abuse icon
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★★ 5
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Individual
- Certified beds
- 122
- Avg residents/day
- 98.2
- Phone
- 2814777771
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-05-29 | 8 | 9.1 | 9.5 | -1.1 better |
| 2 | 2024-03-07 | 5 | 9.4 | 9.8 | -4.4 better |
| 3 | 2022-11-10 | 9 | 8.1 | 9.3 | +0.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 3 |
| Resident assessment and care planning | 1 |
| Resident rights | 1 |
| Pharmacy service | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.27 | 67.8% |
| RN staffing (reported) | 0.24 | 66.7% |
| Total nurse staffing (adjusted) | 3.41 | — |
Fines & penalties
- Total fines
- $74,263
- Number of fines
- 2
- Number of penalties
- 2
- Payment denials
- 0
Chain
- Chain
- MOMENTUM SKILLED SERVICES
- Facilities in chain
- 10
- Chain avg overall
- 2.00 / 5
Inspection citations (22)2 immediate jeopardy
- DF0583Keep residents' personal and medical records private and confidential.2026-01-30 · Health
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2026-01-30 · Health
Potential for more than minimal harm
- DF0761Ensure 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.2026-01-30 · Health
Potential for more than minimal harm
- JF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-05-29 · Health · corrected 2025-04-22
Immediate jeopardy
- EF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-05-29 · Health · corrected 2025-08-06
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2025-05-29 · Health · corrected 2025-08-06
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-05-29 · Health · corrected 2025-08-06
Potential for more than minimal harm
- DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-05-09 · Health · corrected 2025-05-10
Potential for more than minimal harm
- EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-03-07 · Health · corrected 2024-03-26
Potential for more than minimal harm
- KF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-03-07 · Health · corrected 2024-03-26
Immediate jeopardy
- EF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-03-07 · Health · corrected 2024-03-26
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-03-07 · Health · corrected 2024-03-26
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2024-03-07 · Health · corrected 2024-03-26
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-06-30 · Health · corrected 2023-07-28
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2023-05-09 · Health · corrected 2023-05-26
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-05-02 · Health · corrected 2023-05-24
Potential for more than minimal harm
- EF0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.2022-11-10 · Health · corrected 2022-11-16
Potential for more than minimal harm
- EF0727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.2022-11-10 · Health · corrected 2022-11-16
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2022-11-10 · Health · corrected 2022-11-16
Potential for more than minimal harm
- EF0759Ensure medication error rates are not 5 percent or greater.2022-11-10 · Health · corrected 2022-11-16
Potential for more than minimal harm
- DF0761Ensure 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.2022-11-10 · Health · corrected 2022-11-16
Potential for more than minimal harm
- FF0814Dispose of garbage and refuse properly.2022-11-10 · Health · corrected 2022-11-16
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| WEST WHARTON COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2022-05-01 |
| NWH REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-05-01 |
| THREADGILL, SHARLYN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-05-01 |
| THOMPSON, JOHNNY | Individual | CORPORATE OFFICER | — | 2024-07-01 |
| BROAD RIVER HEALTHCARE, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| CLOVER MODERN INVESTMENTS, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| CLOVER PARENT, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| MARTEL FINANCIAL INVESTMENTS, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| THE SMITHERS MANAGEMENT TRUST | Organization | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| COMPTON, CHARLES | Individual | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| COMPTON, JAMES | Individual | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| COMPTON, KRIS | Individual | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
| MARTEL, MICHAEL | Individual | 5% OR GREATER MORTGAGE INTEREST | — | 2022-05-01 |
Other facilities in Cypress
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.