Cycle 1
Health 2025-05-29 · Fire 2025-05-29
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cypress, TX
Cypress Creek Rehabilitation and Healthcare Center
2-star overall rating with 2-star inspections with abuse icon flag with $74,263 in total fines with 8 recent health deficiencies
13600 Birdcall Lane, Cypress, TX
(281) 477-7771
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Momentum Skilled Services
Operator or chain grouping
Approved since
2019-08-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.24
Registered nurse staffing
LPN hours / resident day
1.11
Licensed practical nurse staffing
Aide hours / resident day
1.91
Nurse aide staffing
Weekend hours
2.68
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
68%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
97.1%
0.1 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.5% |
97.9%
5.4 pts worse
|
95.5%
3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.1% |
3.3%
2.2 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
18.9%
7.5 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
10.8%
3.8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.2% |
15.4%
6.2 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
16.1%
1.8 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
15.0%
1.7 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.2%
2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.8% |
89.7%
27.9 pts worse
|
81.7%
19.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
12.0%
4.1 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.7% |
88.0%
34.3 pts worse
|
79.7%
26 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.8% |
25.9%
12.1 pts better
|
23.9%
10.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Not marked corrected
D · Potential for more than minimal harm
2026-01-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Not marked corrected
D · Potential for more than minimal harm
2026-01-30
F761 · Pharmacy Service Deficiencies
Health
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.
Not marked corrected
J · Immediate jeopardy
2025-05-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-05-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-05-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-05-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-10
K · Immediate jeopardy
2024-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-03-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-03-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-03-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-26
D · Potential for more than minimal harm
2023-06-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-05-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-24
F · Potential for more than minimal harm
2022-11-10
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-16
E · Potential for more than minimal harm
2022-11-10
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2022-11-16
E · Potential for more than minimal harm
2022-11-10
F727 · Nursing and Physician Services Deficiencies
Health
Have 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.
Corrected 2022-11-16
E · Potential for more than minimal harm
2022-11-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-11-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-11-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-11-16
Penalties and ownership
What sits behind the stars
$10,361
2025-05-09
Fine
Fine · fine $10,361
Fine
$63,902
2024-03-07
Fine
Fine · fine $63,902
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Broad River Healthcare, LLC
5% Or Greater Mortgage Interest · Organization
Clover Modern Investments, LLC
5% Or Greater Mortgage Interest · Organization
Clover Parent, LLC
5% Or Greater Mortgage Interest · Organization
Compton, Charles
5% Or Greater Mortgage Interest · Individual
Compton, James
5% Or Greater Mortgage Interest · Individual
Compton, Kris
5% Or Greater Mortgage Interest · Individual
Martel Financial Investments, LLC
5% Or Greater Mortgage Interest · Organization
Martel, Michael
5% Or Greater Mortgage Interest · Individual
Nwh Rehab LLC
Operational/Managerial Control · Organization
The Smithers Management Trust
5% Or Greater Mortgage Interest · Organization
Thompson, Johnny
Corporate Officer · Individual
Threadgill, Sharlyn
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Houston, TX
2-star overall rating with 1-star inspections with $40,221 in total fines with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Fallbrook Rehabiliation and Care Center
Houston, TX
1-star overall rating with 1-star inspections with $173,479 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Park Manor Of Cyfair
Houston, TX
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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