Cypress Creek Rehabilitation and Healthcare Center
13600 Birdcall Lane, Cypress, TX 77429
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Follow this homeCypress Creek Rehabilitation and Healthcare Center is a nursing home in Cypress, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionJuly 2, 2026 (4 months ago)
- Health citations since March 7, 202417 (Texas average 28)
- Fines in the past three years2, $74,263 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Health inspection on July 2, 2026
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on July 3, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 3, 2026.
CMS has cited this home for F0880 2 times since 2025.
Citation F0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on July 3, 2026.
CMS update of June 24, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on April 30, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for F0755 2 times since 2024.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of March 25, 2026
Fine
CMS changed the fine from May 9, 2025 from $15,940 to $10,361.
Health inspection on January 30, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on February 2, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on February 2, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 2, 2026.
CMS update of January 14, 2026
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of July 30, 2025
Staffing
Total nurse staffing reported to CMS went from 3.4 to 3.0 hours per resident per day.
Health inspection on May 29, 2025
4 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
Show the 4 citations
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 22, 2025.
CMS has cited this home for F0600 2 times since 2025.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 6, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on August 6, 2025.
CMS has cited this home for F0759 2 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 6, 2025.
Health inspection on May 9, 2025
1 citationCMS lists this as a complaint inspection.
CMS fine of $10,361 on May 9, 2025.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on May 10, 2025.
CMS update of August 29, 2024
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of June 26, 2024
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Health citation
CMS removed citation F0600 from the health inspection on March 7, 2024.
CMS update of May 29, 2024
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on March 7, 2024
5 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $63,902 on March 7, 2024.
Show the 5 citations
Citation F0686. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 26, 2024.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 26, 2024.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on March 26, 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 26, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 26, 2024.
Fire safety inspection on March 7, 2024
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 26, 2024.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS star ratings
- 3 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (281) 477-7771
- Last standard health inspection
- July 2, 2026 (4 months ago)
- Certified beds
- 122
- Residents per day, on average
- 94.3
- Ownership type
- For profit - Limited Liability company
- Legal business name
- West Wharton County Hospital District
- Chain
- Momentum Skilled Services
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (17 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- NWH REHAB LLCOperational/managerial control · not applicable · since 05/01/2022
- THREADGILL, SHARLYNOperational/managerial control · not applicable · since 05/01/2022
Questions
When was Cypress Creek Rehabilitation and Healthcare Center last inspected?
CMS lists July 2, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Cypress Creek Rehabilitation and Healthcare Center have?
CMS lists 17 health citations since March 7, 2024. CMS also calls these deficiencies.
Has Cypress Creek Rehabilitation and Healthcare Center been fined?
CMS lists 2 fines in the past three years, $74,263 in total.
What is the CMS star rating of Cypress Creek Rehabilitation and Healthcare Center?
Its CMS overall star rating is 3 of 5.
Is Cypress Creek Rehabilitation and Healthcare Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.