01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-29 | 6 | 2025-05-29 | 0 |
| Cycle 2 | 2024-03-07 | 8 | 2024-03-07 | 1 |
| Cycle 3 | 2022-11-10 | 6 | 2022-11-10 | 0 |
CMS CCN 6764672026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Cypress Creek Rehabilitation And Healthcare Center
13600 Birdcall Lane · Cypress, TX 77429 · Harris County
Certified beds122CMS provider file
Recent citation rows21current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
21 rows in the current release
2 rows carry G–L scope/severity codes; 2 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-30 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-05-01 · complaint2026-01-30 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2026-02-02 · complaint2026-01-30 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-02 · complaint2026-01-30 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-02 · complaint2025-05-29 · HEALTHF0600Severity J · isolated immediate jeopardy
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.
Correction field: Past Non-Compliance · 2025-04-22 · complaint2025-05-29 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-08-06 · complaint2025-05-29 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-08-062025-05-29 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-062025-05-09 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-05-10 · complaint2024-03-07 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-03-26 · complaint2024-03-07 · HEALTHF0686Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-03-262024-03-07 · HEALTHF0690Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-03-262024-03-07 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-03-26 · complaint2024-03-07 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-03-26 · complaint2024-03-07 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-03-262022-11-10 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2022-11-162022-11-10 · HEALTHF0727Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2022-11-162022-11-10 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2022-11-162022-11-10 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2022-11-162022-11-10 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2022-11-162022-11-10 · HEALTHF0814Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2022-11-1603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-05-09 | Fine | $10,361 | 0 |
| 2024-03-07 | Fine | $63,902 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BROAD RIVER HEALTHCARE, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- CLOVER MODERN INVESTMENTS, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- CLOVER PARENT, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- MARTEL FINANCIAL INVESTMENTS, LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- THE SMITHERS MANAGEMENT TRUSTOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- COMPTON, CHARLESIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- COMPTON, JAMESIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- COMPTON, KRISIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- MARTEL, MICHAELIndividual · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2022
- THOMPSON, JOHNNYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2024
- NWH REHAB LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2022
- THREADGILL, SHARLYNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2022
- SMITHERS, JEFFREYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/26/2025
- THREADGILL, FORRESTIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/26/2025
- THREADGILL, MORGANIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/26/2025
- BROAD RIVER HEALTHCARE, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2022
- CLOVER MODERN INVESTMENTS, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2022
- CLOVER PARENT, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.23per resident day
RN hours0.21per resident day
Weekend nurse hours2.70per resident day
Staff turnover66.7%CMS reported field
06 / LOCAL RECORDS
Open the Texas ledger →Other published facilities nearby
No second facility in the same city met the directory rule.