Cypress Creek Rehabilitation and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II residents reviewed for 1 of 8 residents (Resident #10) reviewed for resident assessment. The facility failed to ensure Resident #10's PASRR Level I screening reflected his mental illness diagnosis. This failure could place residents at risk of not receiving specialized services for their mental illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 laundry areas (Laundry Room) reviewed for infection control. The facility failed to ensure the Housekeeping Manager handled clean linen in a sanitary manner on 7/2/26. The failure could lead to cross contamination or infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 3 of 16 resident rooms (rm 401, RM [ROOM NUMBER], and RM [ROOM NUMBER]) reviewed for pest control.1. The facility failed to ensure occupied resident room [ROOM NUMBER] was free of small black ants. 2. The facility failed to ensure occupied resident room [ROOM NUMBER] was free of flies.3. The facility failed to ensure occupied resident room [ROOM NUMBER] was free of small black ants and winged insects. This failure could place residents at risk of having pests in their rooms and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (CR #1) reviewed for pharmacy services. The facility failed to check CR #1's Vancomycin trough level according to MD orders after every 4th dose every 7 day for 2 weeks. The facility failed to ensure CR #1 did not receive IV Vancomycin after the 4th dose on 12/05/2026 at 7:00 am, without a trough level being obtained on 12/05/2026 at 7 p.m.,12/06/2025 at 7:00 am and 7:00pm, and 12/07/2026 at 7:00 am and 7:00 pm. This failure could cause Vancomycin toxicity, acute kidney injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident has the right to secure and confidential personal and medical records for 1 of 5 residents (Resident #17) reviewed for privacy. The facility failed to protect resident information from unauthorized access when resident medical records were left open, unsecured and visible to others. This failure could result in exposure to sensitive information that could cause embarrassment or emotional distress to a resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 residents (Resident #37). The facility failed to revise the residents' care plan after a documented change in condition for redness to right eye which had worsened. This failure could result in avoidable complications, decline, or injury.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for 2 of 8 (Respiratory Therapist Cart on 100 hall and Nurse Cart on 300 hall) medication carts reviewed for storage of medications. The facility failed to ensure RT P on the 100 hall and LVN T on the 300 hall lock medication carts before walking away and providing care to residents. This failure could place all residents at risk oof unauthorized access to prescription and over-the-counter medications, including controlled substances.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse. CNA A was physically abusive to Resident #1 on 1/28/2025 when he slapped her on the left cheek with an open hand and pointed at her twice aggressively. The noncompliance was identified as past noncompliance (PNC). The IJ (immediate jeopardy) began on 1/28/2025 and ended on 4/22/2025. The facility corrected the noncompliance before the survey began. Resident #2 was physically abusive to Resident #1 on 4/21/2025 when she punched her in the arm with a closed fist three times. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 4/21/25 and ended on 4/22/2025. The facility corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview and record view the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 2 of 6 residents (Residents #3, #1) reviewed for abuse and neglect. The facility failed to report a significant injury of unknown origin to HHSC when Resident #3 was found to have scattered bruising of different colors and a fractured arm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities which involved 2 of 6 residents (Residents #22 and #68) and 2 of 6 staff (MA V and LVN B) reviewed for medication administration. MA V crushed and administered Klor Con ER (an extended-release medication used to prevent or treat low blood levels of potassium) to Resident #22 on 5/14/25. Extended-Release formulations should not be crushed. LVN B administered the wrong Multivitamin to Resident #68 on 5/14/25 according to Physician orders. These failures could place residents at risk of incomplete therapeutic outcomes, increased side effects, or decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #68) reviewed for infection control. -LVN B did not wear appropriate PPE when administering medication via peg-tube (PEG tubes allow you to receive nutrition through your stomach) to Resident #68 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) on 5/14/25. This failure could place residents at risk of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 13 residents (Resident #1) reviewed for abuse. CNA A was verbally abusive to Resident #1 on 04/23/2024 after he used a racial slur (derogatory terms or phrases used to insult, demean, or dehumanize individuals or groups based on their race or ethnicity). This failure placed residents at risk of experiencing anger, depression, and anxiety during staff encounters.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for six of 9 residents (Resident #31, #66, #90, #37, #72 and #11) reviewed for pressure sores. -The facility failed to ensure Resident #31 received wound care treatment for 38 days, did not evaluate, and obtain orders for wound care upon admission when the resident was noted to have an open wound to the buttocks. The right heel had a pressure ulcer that was not identified for further preventative treatment by the discharging hospital, and deteriated after admission - this wound was unavoidable per Wound Care MD. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 2 of 9 residents (Residents #26 and #202) reviewed for quality of care. 1. The facility failed to recognize and assess, Resident #26's scabbed skin injury to the left foot, prior to Surveyor identification on 02/29/2024, resulting in a delay in treatment. 2. The facility failed to identify, evaluate and treat Resident #202's rash upon admission resulting in a delay in treatment. These failures could place residents at risk of pain, worsening of skin issues, delay in treatment, decline in health and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 (Resident #53, Resident #8, and Resident #42) out of 20 residents reviewed for incontinent care. -CNA M failed to change Resident #53's brief for over 5 hours. -CNA J failed to change Resident #8's brief for over 8 hours. -CNA N failed to change Resident #42's brief for over 5 hours. These failures could place residents at risk for dignity issues, skin breakdown, infection, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 2 residents (Residents #8 and #352) reviewed for pharmacy services. The facility failed to ensure LVN A administered Oxycodone-Acetaminophen (a controlled medication used to treat moderate to severe pain) and Lorazepam (a controlled medication that treats anxiety) to Resident #8 in accordance with physician's orders. The facility failed to ensure MA A administered Oxycodone-Acetaminophen to Resident #8 in accordance with physician's orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 5% based on 2 errors out of 34 opportunities, which involved 2 of 6 residents (Residents #57 and #11) reviewed for medication errors. - MA B administered Carvedilol (a medication used to treat high blood pressure and heart failure) to Resident #57 when it should have been held according to the parameters indicated in the physician's orders. - LVN BB administered insulin to Resident #11 during a meal instead of before a meal as indicated in the physician's orders. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.