Cypress Garden Center for Nursing and Rehabilitati

Inspectors wroteBased on observation, record review, and interviews during the abbreviated survey (NY00375573), the facility failed to ensure a resident was protected from abuse of any kind by anyone. This was evident for one (1) out of five (5) residents (Resident #1). Specifically, on 3/19/2025 Licensed Practical Nurse (#1) pulled Resident #1 on to and off the elevator. This was witnessed by Certified Nursing Assistants # 1, #2, Security Guard #1, and Registered Nurse Supervisor #1.

Inspectors wroteBased on observations and staff interviews during the re-certification survey, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of resident equipment layered with dirt and dust, room furniture heavily worn and torn seat cushion, room walls with streaks and stains, ice machines covered with rust stains, floor corners embedded with grime and dirt, base of dining room tables heavily worn and rust stains, nurse station area floor and walls layered with dirt and dust and entangled loose wires, torn or stained privacy curtains. This was evident for 3 of 7 units. (Units: 3, 4 and 6).

Inspectors wroteBased on observation and interview, during the re-certification survey, the facility did not ensure the resident and staff physical environment was kept safe and clean. Specifically, 1.) Nurse Station 2.) Lobby Restrooms and Floor Tiles 3.) Staff Bathroom. This was evident in the Lobby area including 3 of 7 units. ( Units 3, 4 and 6).

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification survey from 9/16/2024 to 9/23/2024, the facility did not ensure that a Comprehensive Care Plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to Communication: vision/hearing, was not revised based on a resident's need for a hearing aid. This was evident for 1 (Resident #207) of 3 residents reviewed for Communication' vision/hearing, out of 38 total sampled residents.

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. Specifically, Resident #160 was observed on several occasions the hearing aid in place. This was evident for 1 (Resident #160 ) of 2 residents reviewed for Communication and Hearing Care Area. The finding is: The facility policy and procedure dated, 01/05/24 titled, Hearing Impaired and Care of, documented, 'It is the policy of the facility staff will assist hearing impaired residents maintain effective communication with clinicians, caregivers and other residents. Resident #160 has diagnoses including but not limited to Hearing Loss, Hypertension and Cerebral Vascular Accident. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 09/16/2024 to 09/23/2024, the facility did not ensure a resident right to self-determination was honored. This was evident for 1 of 3 Residents (Resident #69) investigated for Abuse out of a total sample of 35 Residents. Specifically, Certified Nursing Assistant repeatedly attempted to render care to Resident #69 despite Resident #69 refusing care.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey conducted from 6/27/22 to 7/5/22, the facility did not ensure a resident was provided with the necessary services to carry out activities of daily living (ADL). This was evident for 1 (Resident #143) of 2 residents reviewed for ADLs. Specifically, there were multiple observations of Resident #143 with long uncut toenails.

Inspectors wroteBased on observation and staff interviews during recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, potentially hazardous cold foods (sandwiches) were not maintained at the proper temperature (at or below 41 degrees Fahrenheit), and equipment used to slice meat for sandwiches was not properly cleaned after use. This was evident during the Kitchen Observation facility task.

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not ensure that a homelike environment was provided. Specifically, resident rooms were observed with bare white walls and lacking decor, creating a colorless, dull environment. This was observed for 3 residents (Resident #s 110, 218, and 204) on one (1) of six (6) resident units (Unit 3).

Inspectors wroteBased on observation, record review, and interview during the re-certification survey, the facility did not ensure that each resident was treated with dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, a resident was observed wearing oversized soiled and tattered sneakers with no socks. This was evident for one (1) of one (1) resident reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that medically related social services to attain and maintain the highest practicable physical, mental and psychological well - being of each resident were provided. Specifically, a resident observed wearing oversized, soiled, and tattered sneakers without socks was not assisted with obtaining new footwear and socks. This was evident for one (1) of one (1) residents reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. [...]

Inspectors wroteBased on observations, interviews, and record review during the Re-Certification Survey, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition. Specifically, a resident with wandering and elopement risk behaviors was prescribed psychotropic medications without an appropriate diagnosis. In addition, the facility did not attempt any non-pharmacological interventions targeted to address the psychosocial stressors of loss of home and family moving away that contributed to the behavior prior to starting the medication. This was evident for one (1) of five (5) residents investigated for Unnecessary Medication (Resident # 51). The finding is: The policy for, Psychotropic Drugs & GDR (Gradual Dose Reduction), dated 03/20/19, documented the following: [...]

Inspectors wroteBased on observation and staff interviews during the recertification survey, the facility did not ensure the infection prevention and control program desgned to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained. Specifically, the consultant eye doctor did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam. This was evident for 1 random observation (Resident #199) on 1 out of 6 resident units (2nd floor). The finding is: The facility policy titled Handwashing, reviewed and revised on 7/2017, documented that handwashing should be done before and after resident contact. Proper handwashing technique includes the following steps: Wet hands with running water. Apply soap and throughtly distributed over hands. [...]