Cypress Creek Rehabilitation and Healthcare Center
Grade D — 61/100 composite score
CMS Star Ratings
Certified Beds
122
Ownership
For profit - Corporation
Total Fines
$79,842
Last Survey
N/A
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Staffing Hours & Turnover
Hours per Resident per Day (PBJ)
Turnover Rates
Ownership
WEST WHARTON COUNTY HOSPITAL DISTRICT
100%
NWH REHAB LLC
THREADGILL, SHARLYN
THOMPSON, JOHNNY
BROAD RIVER HEALTHCARE, LLC
CLOVER MODERN INVESTMENTS, LLC
CLOVER PARENT, LLC
MARTEL FINANCIAL INVESTMENTS, LLC
THE SMITHERS MANAGEMENT TRUST
COMPTON, CHARLES
COMPTON, JAMES
COMPTON, KRIS
MARTEL, MICHAEL
Penalties & Fines (2)
| Date | Type | Description | Amount |
|---|---|---|---|
| May 9, 2025 | Fine | — | $15,940 |
| Mar 7, 2024 | Fine | — | $63,902 |
Health Inspection Deficiencies (20)
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
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
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
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
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
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
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
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies
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
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
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
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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.