F

Cypress Creek Rehabilitation and Healthcare Center

13600 Birdcall Lane, Cypress, TX 77429
Score: 28 / 100

Cypress Creek Rehabilitation And Healthcare Center has received an F grade based on CMS data, with a score of 28/100 — placing it among the lowest-rated nursing facilities in Texas. Families considering this Cypress facility should carefully review its inspection history and quality metrics.

With 3.27 total nurse hours per resident per day, Cypress Creek Rehabilitation And Healthcare Center falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.

Recent CMS inspections identified 22 deficiencies at Cypress Creek Rehabilitation And Healthcare Center, including 2 classified as serious — among the most concerning citation levels. The most notable finding involved: keep residents' personal and medical records private and confidential..

Score Breakdown

Overall CMS Rating 16 / 40 pts
2 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 4 / 20 pts
1 ★ staffing rating
Quality Measures 15 / 15 pts
5 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.27 3.8 Below Average
Registered Nurses (RN) 0.24 0.7 Below Average
Licensed Practical Nurses (LPN) 1.11 0.7 Above Average
Certified Nursing Assistants (CNA) 1.91 2.4 Below Average
Weekend Total Nursing 2.68 3.8 Below Average
Weekend RN Hours 0.11 0.7 Below Average

🔍 Inspection & Deficiency History

22
Total Deficiencies
Jan 29, 2026
Most Recent Inspection
🟠 20 Moderate 🔴 2 Serious
View recent deficiencies (5 shown)
  • Tag 0583 Severity D
    Keep residents' personal and medical records private and confidential.
    Jan 29, 2026 · Resident Rights Deficiencies
  • Tag 0656 Severity D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Jan 29, 2026 · Resident Assessment and Care Planning Deficiencies
  • Tag 0761 Severity D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologi
    Jan 29, 2026 · Pharmacy Service Deficiencies
  • Tag 0600 Severity J
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    May 28, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0609 Severity E
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    May 28, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 2.2% 4.5% Better
Falls with major injury 2.8% 3.0% Average
On antipsychotic medication 7.0% 14.5% Better
Urinary tract infections 0.0% 2.5% Better
ADL decline (daily activities) 14.3% 14.0% Average
Excessive weight loss 1.1% 7.5% Better
New/worsened incontinence 13.3% 45.0% Better

⚠️ Penalties & Fines

2 penalties recorded by CMS

Total fines: $74,263

How This Grade Was Calculated

This facility's grade of F is based on a score of 28 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 2★ → 16 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 1★ → 4 pts (max 20)
  • Quality Measures Rating: 5★ → 15 pts (max 15)
  • Penalty deductions: -10 pts
  • Fine deductions: -7 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Individual
Certified Beds
122
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
May 28, 2025
Deficiencies (Cycle 1)
8