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
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.24
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,559
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.9
Baseline 22.46% · Performance 18.98% · Measure score 5.9 · Achievement 5.28 · Improvement 5.9
Healthcare-associated infections
0
Baseline 8.09% · Performance 9.38% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 76.40% · Performance 79.83% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.62
Baseline 2.64 hours · Performance 2.99 hours · Measure score 0.62 · Achievement 0 · Improvement 0.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 10.81% · Lower 95% interval 7.51% |
| Discharge to community | 58.69% |
50.57%
8.1 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 49.37% · Lower 95% interval 46.21% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.22% |
95.27%
2 pts better
|
Numerator 70 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 37.84% |
53.69%
15.8 pts worse
|
Numerator 14 · Denominator 37 |
| Discharge mobility score | 43.24% |
50.94%
7.7 pts worse
|
Numerator 16 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 3 · Denominator 72 · Adjusted rate 2.89% |
| Healthcare-associated infections requiring hospitalization | 9.38% |
7.12%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 14.71% · Lower 95% interval 5.5% |
| Staff COVID-19 vaccination coverage | 2.65% |
8.2%
5.5 pts worse
|
Numerator 3 · Denominator 113 |
| Staff flu vaccination coverage | 14.98% |
42%
27 pts worse
|
Numerator 31 · Denominator 207 |
| Discharge function score | 40.54% |
56.45%
15.9 pts worse
|
Numerator 15 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 5 · Denominator 20 |
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 · Adjusted 2.7 · Observed 3.6 · Expected 2.5 · Used in QM five-star |
| 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 · Adjusted 2.1 · Observed 2.3 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 97.8% · Q2 98.9% · Q3 97.7% · Q4 94.4% · 4Q avg 97.2% |
| 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 · 4Q avg 92.5% |
| 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 · Q1 5.6% · Q2 1.1% · Q3 1.2% · Q4 3.4% · 4Q avg 2.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.3% · 4Q avg 0.6% |
| 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 · Q1 1.4% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.1% |
| 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 · Q1 16.9% · Q2 9.5% · Q3 5.7% · Q4 13.0% · 4Q avg 11.4% |
| 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 · Q1 6.6% · Q2 5.5% · Q3 8.8% · Q4 7.3% · 4Q avg 7.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 17.2% · Q2 0.0% · Q4 8.4% · 4Q avg 9.2% · Used in QM five-star |
| 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 · Q1 16.7% · Q2 14.7% · Q3 11.1% · Q4 14.5% · 4Q avg 14.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 15.5% · Q2 8.0% · Q3 20.1% · Q4 9.3% · 4Q avg 13.3% |
| 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 · Q1 2.7% · Q2 1.7% · Q3 1.7% · Q4 2.9% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 78.9% · Q2 60.0% · Q3 53.8% · Q4 51.8% · 4Q avg 61.8% |
| 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 · Adjusted 7.9% · Observed 8.7% · Expected 12.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| 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 · 4Q avg 53.7% |
| 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 · Adjusted 13.8% · Observed 15.2% · Expected 26.2% · Used in QM five-star |
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
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