Map showing the location of Cypress Creek Rehabilitation and Healthcare Center in Cypress, Texas
13600 Birdcall Lane, Cypress, TX, 77429

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasAbove only 23% of peers1,167 rated homes · average 2.8★
  • Harris CountyAbove only 26% of peers94 rated homes · average 2.8★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs TX avg
  • StaffingCan add or remove a star1★−1.1 vs TX avg
  • Quality measuresCan add or remove a star5★+1.2 vs TX avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 68% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.27hrsAbove only 48% of peersTX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.24hrsAbove only 15% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better68%Above only 13% of peersTX avg51%RN turnover67%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$79,842Above only 22% of peersTX avg$55,368Fines · denials2 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
19citations
7inspection dates
0actual harm (G–I)
2immediate jeopardy (J–L)
May 29, 2025most recent

Citations by monthNov 2022 – May 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

May 29, 20254 citationsCycle 1worst J · immediate jeopardy$15,940
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 6, 2025
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Apr 22, 2025
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Aug 6, 2025
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Aug 6, 2025
May 9, 20251 citationCycle 1worst D · no actual harm$15,940
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 10, 2025
Mar 7, 20245 citationsCycle 2worst K · immediate jeopardy$63,902
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Mar 26, 2024
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareK · patternCorrected Mar 26, 2024
  3. F690Provide 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 CareE · patternCorrected Mar 26, 2024
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Mar 26, 2024
  5. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Mar 26, 2024
Jun 30, 20231 citationCycle 3worst D · no actual harm
  1. F656Develop 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 PlanningD · isolatedCorrected Jul 28, 2023
May 9, 20231 citationCycle 3worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 26, 2023
May 2, 20231 citationCycle 3worst E · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected May 24, 2023
Nov 10, 20226 citationsCycle 3worst F · no actual harm
  1. F584Honor 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 RightsE · patternCorrected Nov 16, 2022
  2. F727Have 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 ServicesE · patternCorrected Nov 16, 2022
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 16, 2022
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Nov 16, 2022
  5. F761Ensure 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 ServiceD · isolatedCorrected Nov 16, 2022
  6. F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Nov 16, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.27hrsAbove only 48% of peers−0.13 vs TX avg
  • Registered nursesRN hours only0.24hrsAbove only 15% of peers−0.20 vs TX avg
  • Licensed practical nursesLPN hours1.11hrs
  • Nurse aidesCNA hours1.91hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.68hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better68%Above only 13% of peersTX avg 51%
  • RN turnoverRegistered nurses only67%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy122 certified beds · ~98 residents a day80%Above 76% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $79,842In fines
  • 2Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above only 22% of peersFewer fines than 22% of rated homes in Texas

Actions on record

  1. May 9, 2025Civil money penalty$15,940
  2. Mar 7, 2024Civil money penalty$63,902

Ownership

As filed with CMS

Structure

Ownership type
For profit - Individual
Chain
Momentum Skilled Services9 facilities in the chain2.1★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • West Wharton County Hospital District
Operational or managerial control
  • Nwh Rehab LLC
  • Sharlyn Threadgill
Corporate officers
  • Johnny Thompson
Mortgage or security interest (5%+)
  • Broad River Healthcare, LLC
  • Clover Modern Investments, LLC
  • Clover Parent, LLC
  • Martel Financial Investments, LLC
  • The Smithers Management Trust
  • Charles Compton
  • James Compton
  • Kris Compton
  • +1 more

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 676467 · 13600 Birdcall Lane, Cypress, TX, 77429.
  • Percentiles compare this facility with every rated nursing home in Texas and Harris County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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