D61

Cypress Creek Rehabilitation and Healthcare Center

Grade D 61/100 composite score

For profit - CorporationAbuse Citation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
5/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

122

Ownership

For profit - Corporation

Total Fines

$79,842

Last Survey

N/A

13600 Birdcall Lane, Cypress, TX 77429
2814777771

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.26h
LPN
1.16h
CNA
2.00h
Total
3.41h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

WEST WHARTON COUNTY HOSPITAL DISTRICT

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2022

100%

NWH REHAB LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince May 2022

THREADGILL, SHARLYN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2022

THOMPSON, JOHNNY

IndividualCORPORATE OFFICERSince Jul 2024

BROAD RIVER HEALTHCARE, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince May 2022

CLOVER MODERN INVESTMENTS, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince May 2022

CLOVER PARENT, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince May 2022

MARTEL FINANCIAL INVESTMENTS, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince May 2022

THE SMITHERS MANAGEMENT TRUST

Organization5% OR GREATER MORTGAGE INTERESTSince May 2022

COMPTON, CHARLES

Individual5% OR GREATER MORTGAGE INTERESTSince May 2022

COMPTON, JAMES

Individual5% OR GREATER MORTGAGE INTERESTSince May 2022

COMPTON, KRIS

Individual5% OR GREATER MORTGAGE INTERESTSince May 2022

MARTEL, MICHAEL

Individual5% OR GREATER MORTGAGE INTERESTSince May 2022

Penalties & Fines (2)

$79,842total fines
DateTypeDescriptionAmount
May 9, 2025Fine$15,940
Mar 7, 2024Fine$63,902

Health Inspection Deficiencies (20)

May 29, 2025Health2 deficiencies1 severe
0600JImmediate jeopardy, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 22, 2025
0609EMinimal harm, Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 6, 2025
May 9, 2025Health1 deficiency
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 10, 2025
March 7, 2024Health5 deficiencies1 severe
0686KImmediate jeopardy, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Mar 26, 2024
0690EMinimal harm, Pattern

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Mar 26, 2024
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 26, 2024
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Mar 26, 2024
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Mar 26, 2024
June 30, 2023Health1 deficiency
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 28, 2023
May 9, 2023Health1 deficiency
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 26, 2023
May 2, 2023Health1 deficiency
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected May 24, 2023
November 10, 2022Health6 deficiencies
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Nov 16, 2022
0727EMinimal harm, Pattern

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.

Nursing and Physician Services Deficiencies

Corrected Nov 16, 2022
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Nov 16, 2022
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Nov 16, 2022
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Nov 16, 2022
0814FMinimal harm, Widespread

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Nov 16, 2022
August 26, 2021Health3 deficiencies
0693DMinimal harm, Isolated

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies

Corrected Sep 3, 2021
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Sep 3, 2021
0757EMinimal harm, Pattern

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Sep 3, 2021

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Frequently Asked Questions

What is the CareGrader rating for Cypress Creek Rehabilitation and Healthcare Center?

Cypress Creek Rehabilitation and Healthcare Center in Cypress, Texas has a CareGrader grade of D (Below Average), with a composite score of 61.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Cypress Creek Rehabilitation and Healthcare Center?

Cypress Creek Rehabilitation and Healthcare Center has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Cypress Creek Rehabilitation and Healthcare Center have?

Cypress Creek Rehabilitation and Healthcare Center has 20 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has Cypress Creek Rehabilitation and Healthcare Center been fined?

Yes. Cypress Creek Rehabilitation and Healthcare Center has $79,842 in total fines from CMS enforcement actions across 2 penalties.

How many beds does Cypress Creek Rehabilitation and Healthcare Center have?

Cypress Creek Rehabilitation and Healthcare Center has 122 certified beds with approximately 98 current residents (80% occupancy). The facility is located at 13600 Birdcall Lane, Cypress, Texas 77429. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.