Cypress Creek Rehabilitation And Healthcare Center

Penalties

• May 9, 2025 — Fine ($10,361)
• Mar 7, 2024 — Fine ($63,902)

Inspection findings

1. Apr 30, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 1, 2026 · CMS health inspection

2. Jan 30, 2026 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Feb 2, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Feb 2, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 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.

     Corrected Feb 2, 2026 · CMS health inspection

3. May 29, 2025 Health · 4 findings
   • Serious Scope/severity J Complaint

     F0600 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.

     Corrected Apr 22, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Aug 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 6, 2025 · CMS health inspection

4. May 9, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 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.

     Corrected May 10, 2025 · CMS health inspection

5. Mar 7, 2024 Health · 6 findings
   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 26, 2024 · CMS health inspection

   • Serious Scope/severity K

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0690 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.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Mar 26, 2024 · CMS fire safety

6. Nov 10, 2022 Health · 6 findings
   • Not serious Scope/severity E

     F0584 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.

     Corrected Nov 16, 2022 · CMS health inspection

   • Not serious Scope/severity E

     F0727 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.

     Corrected Nov 16, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Nov 16, 2022 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Nov 16, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Nov 16, 2022 · CMS health inspection

   • Not serious Scope/severity F

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Nov 16, 2022 · CMS health inspection

Owners and managers (as published by CMS)

• COMPTON, CHARLES — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• COMPTON, CHARLES — adp of the snf, NOT APPLICABLE, since 05/01/2022
• COMPTON, JAMES — adp of the snf, NOT APPLICABLE, since 05/01/2022
• COMPTON, JAMES — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• COMPTON, KRIS — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• COMPTON, KRIS — adp of the snf, NOT APPLICABLE, since 05/01/2022
• MARTEL, MICHAEL — adp of the snf, NOT APPLICABLE, since 05/01/2022
• MARTEL, MICHAEL — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• SMITHERS, JEFFREY — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/26/2025
• SUTER, RACHEL — adp of the snf, NOT APPLICABLE, since 06/27/2016
• THOMPSON, JOHNNY — corporate officer, NOT APPLICABLE, since 07/01/2024
• THREADGILL, FORREST — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/26/2025
• THREADGILL, MORGAN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/26/2025
• THREADGILL, SHARLYN — operational/managerial control, NOT APPLICABLE, since 05/01/2022
• WHITE, KARA — adp of the snf, NOT APPLICABLE, since 09/17/2024
• BROAD RIVER HEALTHCARE, LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• BROAD RIVER HEALTHCARE, LLC — adp of the snf, NOT APPLICABLE, since 05/01/2022
• CLOVER MODERN INVESTMENTS, LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• CLOVER MODERN INVESTMENTS, LLC — adp of the snf, NOT APPLICABLE, since 05/01/2022
• CLOVER PARENT, LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• CLOVER PARENT, LLC — adp of the snf, NOT APPLICABLE, since 05/01/2022
• MARTEL FINANCIAL INVESTMENTS, LLC — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• MARTEL FINANCIAL INVESTMENTS, LLC — adp of the snf, NOT APPLICABLE, since 05/01/2022
• NWH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2022
• THE SMITHERS MANAGEMENT TRUST — 5% or greater mortgage interest, NOT APPLICABLE, since 05/01/2022
• THE SMITHERS MANAGEMENT TRUST — adp of the snf, NOT APPLICABLE, since 05/01/2022