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Cypress Creek Rehabilitation And Healthcare Center

13600 Birdcall Lane, Cypress, TX 77429
2814777771
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Overall CMS Rating

2.0/5

vs State Average: 2.8 stars

2.0/5

Health Inspections

vs State Average: 2.8/5

1.0/5

Staffing Level

vs State Average: 2.1/5

5.0/5

Quality Measures

vs State Average: 3.8/5

2 penalties in last 3 years
Penalties
vs State Average: 1.8 penalties

About This Facility

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Ratings Deep Dive

Score
2.0
State Average
2.8
National Average
2.8
5 Deficiencies found in last inspections
2 Penalties in last 3 years
2 Fines issued
Citation Date Description Severity
May 29, 2025 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. E
May 29, 2025 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. J
May 29, 2025 Ensure medication error rates are not 5 percent or greater. D
May 29, 2025 Provide and implement an infection prevention and control program. D
May 9, 2025 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D
Score
1.0
State Average
2.1
National Average
2.9
0.2 RN Hours / Resident / Day
3.3 Total Nurse Hours / Resident / Day
66.7% RN Turnover Rate
Score
5.0
State Average
3.8
National Average
3.6
5.0 Long-Stay QM Rating
5.0 Short-Stay QM Rating
98.2 Avg Residents Per Day
Measure Score Type
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay
Percentage of long-stay residents who lose too much weight Long Stay
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay
Percentage of long-stay residents with a urinary tract infection Long Stay
Percentage of long-stay residents who have depressive symptoms Long Stay
Percentage of long-stay residents who were physically restrained Long Stay
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay

Ownership & Compliance

Ownership Info
5% OR GREATER DIRECT OWNERSHIP INTEREST WEST WHARTON COUNTY HOSPITAL DISTRICT
OPERATIONAL/MANAGERIAL CONTROL NWH REHAB LLC
OPERATIONAL/MANAGERIAL CONTROL THREADGILL, SHARLYN
CORPORATE OFFICER THOMPSON, JOHNNY
5% OR GREATER MORTGAGE INTEREST BROAD RIVER HEALTHCARE, LLC
5% OR GREATER MORTGAGE INTEREST CLOVER MODERN INVESTMENTS, LLC
5% OR GREATER MORTGAGE INTEREST CLOVER PARENT, LLC
5% OR GREATER MORTGAGE INTEREST MARTEL FINANCIAL INVESTMENTS, LLC
5% OR GREATER MORTGAGE INTEREST THE SMITHERS MANAGEMENT TRUST
5% OR GREATER MORTGAGE INTEREST COMPTON, CHARLES
Recent Penalties
Date Type Fine
May 9, 2025 Fine $15,940
Mar 7, 2024 Fine $63,902

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