Cypress Creek Rehabilitation and Healthcare Center
13600 Birdcall Lane, Cypress, TX 77429 · Harris County · 122 certified beds · avg 92 residents/day · certified since Aug 22, 2019
Part of chain: MOMENTUM SKILLED SERVICES (9 facilities, chain avg rating 2.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · May 29, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 22, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, repeated · Mar 7, 2024 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 26, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (20)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 30, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| May 29, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 29, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 29, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 29, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 9, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 7, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 7, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 7, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 7, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 7, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Nov 10, 2022 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Nov 10, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Nov 10, 2022 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Nov 10, 2022 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Nov 10, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 10, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 6 | 0 | F |
| 2024 | 5 | 1 | K ▲ |
| 2025 | 5 | 1 | J ▲ |
| 2026 | 4 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $74,263.
| Date | Type | Amount / length |
|---|---|---|
| May 9, 2025 | Fine | $10,361 |
| Mar 7, 2024 | Fine | $63,902 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.38 | 3.46 | 3.95 | top 44% in Texas; bottom 30% in the U.S. |
| Registered Nurse hours | 0.22 | 0.44 | 0.69 | bottom 10% in Texas; bottom 3% in the U.S. |
| Weekend total nurse staffing | 2.83 | 3.04 | 3.50 | bottom 42% in Texas; bottom 22% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.09 | 0.34 | 0.48 | bottom 2% in Texas; bottom 1% in the U.S. |
| Total nursing staff turnover (%) | 66.7 | 55.3 | 45.8 | bottom 23% in Texas; bottom 8% in the U.S. |
| RN turnover (%) | 87.5 | 54.6 | 42.9 | bottom 13% in Texas; bottom 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.23, RN 0.21, weekend 2.70. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Broad River Healthcare, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Broad River Healthcare, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Clover Modern Investments, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Clover Modern Investments, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Clover Parent, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Clover Parent, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Compton, Charles | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Compton, Charles | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Compton, James | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Compton, James | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Compton, Kris | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Compton, Kris | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Martel Financial Investments, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Martel Financial Investments, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Martel, Michael | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
| Martel, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| NWH Rehab LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2022 |
| Smithers, Jeffrey | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/26/2025 |
| Suter, Rachel | Individual | ADP of the SNF | NOT APPLICABLE | 06/27/2016 |
| The Smithers Management Trust | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 05/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Eagle Crest Rapid Recovery | 2.5 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuse |
| Fallbrook Rehabilitation and Care Center | 3.3 mi | Houston, TX | ★☆☆☆☆ | 1/5 | SFF |
| Park Manor of Cyfair | 3.3 mi | Houston, TX | ★★★★★ | 5/5 | |
| Cypress Pointe Health & Wellness | 3.5 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| North Houston Transitional Care | 4.0 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| Misty Willow Healthcare and Rehabilitation Center | 4.3 mi | Houston, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Copperfield Healthcare and Rehabilitation | 4.9 mi | Houston, TX | ★★★☆☆ | 2/5 | |
| Champions Healthcare at Willowbrook | 5.2 mi | Houston, TX | ★★☆☆☆ | 2/5 | abuse |
| Willow Creek Lodge | 5.3 mi | Tomball, TX | ★★★☆☆ | 4/5 | |
| Legend Oaks Healthcare and Rehabilitation Center - | 6.1 mi | Houston, TX | ★★☆☆☆ | 2/5 | |
| Paradigm at Woodwind Lakes | 7.5 mi | Houston, TX | —/5 | SFF | |
| The Heights of Tomball | 8.7 mi | Tomball, TX | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676467.