Federal inspection record · CMS data as of October 1, 2026
Cypress Creek Rehabilitation and Healthcare Center
13600 Birdcall Lane, Cypress, TX · (281) 477-7771
- Certified beds
- 122
- Residents per day
- 94
- Ownership
- For-Profit
- Chain
- Momentum Skilled Services
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- August 22, 2019
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Cypress Creek Rehabilitation and Healthcare Center carries 36 inspection points. That is fewer than 81% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
17 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
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J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Pharmacy Service5E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
Ensure medication error rates are not 5 percent or greater.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
Resident Assessment and Care Planning2D
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Infection Control2D
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation2E
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care2E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Environmental1D
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Resident Rights1D
- D
Keep residents' personal and medical records private and confidential.
Inspection history
2026-07-02
7 health deficiencies · 0 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2025-05-29
5 health deficiencies · 0 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2024-03-07
5 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 5 min of nursing staff time a day, 11 min of it from a registered nurse.
This home
3 h 5 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 66% of nursing staff and 86% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$74,263 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-05-09 | Fine | $10,361 |
| 2024-03-07 | Fine | $63,902 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.9 pts worse | 2.9 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.4 pts worse | 2.4 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.2 pts better | 96.6% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3.5 pts worse | 93.5% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.2 pts worse | 5.4% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.4 pts better | 1.9% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.1 pts better | 0.8% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.9 pts better | 11.9% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.6 pts better | 9.2% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.9 pts worse | 13.8% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased2.6 pts worse | 18.4% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.1 pts worse | 12.6% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.7 pts better | 3.0% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine12.3 pts worse | 76.4% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.3 pts better | 11.9% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine2.3 pts better | 87.7% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.9 pts worse | 29.4% | 25.5% | 23.4% |
·
Who owns and runs it
26 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Broad River Healthcare, LLC | 5% Or Greater Mortgage Interest · Organization | 0% | 3 facilities |
| Broad River Healthcare, LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Clover Modern Investments, LLC | 5% Or Greater Mortgage Interest · Organization | 0% | 1 facilities |
| Clover Modern Investments, LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Clover Parent, LLC | 5% Or Greater Mortgage Interest · Organization | 0% | 1 facilities |
| Clover Parent, LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Compton, Charles | 5% Or Greater Mortgage Interest · Individual | 0% | 5 facilities |
| Compton, Charles | Adp Of The SNF · Individual | 0% | 5 facilities |
| Compton, James | 5% Or Greater Mortgage Interest · Individual | 0% | 5 facilities |
| Compton, James | Adp Of The SNF · Individual | 0% | 5 facilities |
| Compton, Kris | 5% Or Greater Mortgage Interest · Individual | 0% | 5 facilities |
| Compton, Kris | Adp Of The SNF · Individual | 0% | 5 facilities |
| Martel Financial Investments, LLC | 5% Or Greater Mortgage Interest · Organization | 0% | 2 facilities |
| Martel Financial Investments, LLC | Adp Of The SNF · Organization | 0% | 2 facilities |
| Martel, Michael | 5% Or Greater Mortgage Interest · Individual | 0% | 7 facilities |
| Martel, Michael | Adp Of The SNF · Individual | 0% | 7 facilities |
| Nwh Rehab LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Smithers, Jeffrey | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 3 facilities |
| Suter, Rachel | Adp Of The SNF · Individual | 0% | 3 facilities |
| The Smithers Management Trust | 5% Or Greater Mortgage Interest · Organization | 0% | 5 facilities |
| The Smithers Management Trust | Adp Of The SNF · Organization | 0% | 5 facilities |
| Thompson, Johnny | Corporate Officer · Individual | 0% | 79 facilities |
| Threadgill, Forrest | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 9 facilities |
| Threadgill, Morgan | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 9 facilities |
| Threadgill, Sharlyn | Operational/Managerial Control · Individual | 0% | 10 facilities |
| White, Kara | Adp Of The SNF · Individual | 0% | 1 facilities |
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Fire safety
1 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke1E
- E
Have approved installation, maintenance and testing program for fire alarm systems.
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