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Cypress Creek Rehabilitation and Healthcare Center
13600 Birdcall Lane, Cypress, TX 77429 · CMS Certification Number (CCN) 676467
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 17 in the last 3 inspection cycles (2 immediate jeopardy, 0 actual harm, 10 from complaints)
- Fire safety citations
- 1
- Fines (last 3 years)
- 2 fines, total $74,263
- Payment denials
- 0
- Most recent standard inspection
- July 2, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 2.7 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | July 2, 2026 | 7 | 3 | 4 |
| Cycle 2 | May 29, 2025 | 8 | 2 | 6 |
CMS weighted health inspection score: 36 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
17 health citations across 6 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 2, 2026: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2026 |
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2026 |
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2026 |
April 30, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/01/2026 |
January 30, 2026: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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 | Complaint | Deficient, Provider has date of correction Corrected 02/02/2026 |
| D | F-0656 | 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 | Complaint | Deficient, Provider has date of correction Corrected 02/02/2026 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/02/2026 |
May 29, 2025: 4 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/06/2025 |
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/06/2025 |
| E | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/06/2025 |
| J | F-0600 | 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 | Complaint | Past Non-Compliance Corrected 04/22/2025 |
May 9, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0600 | 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 | Complaint | Deficient, Provider has date of correction Corrected 05/10/2025 |
March 7, 2024: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/26/2024 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/26/2024 |
| E | F-0690 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/26/2024 |
| K | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/26/2024 |
| E | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/26/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
1 fire safety citations across 1 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 03/07/2024 | E | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/26/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| May 9, 2025 | Fine | $10,361 | — |
| March 7, 2024 | Fine | $63,902 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.23 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.21 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.98 | Not published | Not published |
| Nurse aide hours per resident per day | 2.04 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.7 | Not published | Not published |
| RN hours per resident per day, weekends | 0.09 | Not published | Not published |
| Total nursing staff turnover (%) | 66.7 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 87.5 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- West Wharton County Hospital District
- Ownership type
- For profit - Limited Liability company
- Chain
- Momentum Skilled Services (9 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 122
- Average residents per day
- 91.5
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- August 22, 2019
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
26 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| BROAD RIVER HEALTHCARE, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CLOVER MODERN INVESTMENTS, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CLOVER PARENT, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL FINANCIAL INVESTMENTS, LLC | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THE SMITHERS MANAGEMENT TRUST | 5% OR GREATER MORTGAGE INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, CHARLES | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, JAMES | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, KRIS | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL, MICHAEL | 5% OR GREATER MORTGAGE INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| THOMPSON, JOHNNY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NWH REHAB LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THREADGILL, SHARLYN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITHERS, JEFFREY | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| THREADGILL, FORREST | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| THREADGILL, MORGAN | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BROAD RIVER HEALTHCARE, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CLOVER MODERN INVESTMENTS, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CLOVER PARENT, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL FINANCIAL INVESTMENTS, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THE SMITHERS MANAGEMENT TRUST | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, CHARLES | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, JAMES | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| COMPTON, KRIS | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MARTEL, MICHAEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SUTER, RACHEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WHITE, KARA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Cypress Creek Rehabilitation and Healthcare Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.