Cypress Creek Rehabilitation and Healthcare Center
13600 Birdcall Lane
Cypress, TX, 77429
2814777771
CCN: 676467
2
Overall2
Health1
Staffing5
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| WEST WHARTON COUNTY HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| MARTEL, MICHAEL | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| COMPTON, CHARLES | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| COMPTON, JAMES | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| COMPTON, KRIS | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| BROAD RIVER HEALTHCARE, LLC | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| CLOVER MODERN INVESTMENTS, LLC | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| CLOVER PARENT, LLC | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| MARTEL FINANCIAL INVESTMENTS, LLC | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| THE SMITHERS MANAGEMENT TRUST | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| THOMPSON, JOHNNY | CORPORATE OFFICER | NOT APPLICABLE |
| THREADGILL, SHARLYN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| NWH REHAB LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Penalties (2)
| Date | Type | Amount |
|---|---|---|
| 2025-05-09 | Fine | $10K |
| 2024-03-07 | Fine | $64K |
Health Deficiencies (22)
2026-01-30 · Health
D
F761 · 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.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2025-05-29 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
E
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
J
F600 · 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.
2025-05-09 · Health
D
F600 · 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.
2024-03-07 · Health
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F690 · 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.
K
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2023-06-30 · Health
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2023-05-09 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2023-05-02 · Health
E
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
2022-11-10 · Health
F
F814 · Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
D
F761 · 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.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F727 · Nursing and Physician Services 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.
E
F584 · Resident Rights 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.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.27
RN Hrs/Resident/Day0.54
0.24
LPN Hrs/Resident/Day0.81
1.11
CNA Hrs/Resident/Day2.33
1.91
PT Hrs/Resident/Day0.12
0.06
Data as of 2026-03-01