Cypress Grove Post Acute

Inspectors wroteBased on facility policy review, the facility Treat in Place Protocol review, medical record review, observation, and interview, the facility failed to follow physician orders for the use of oxygen for 1 of 2 (Resident #5) sampled residents reviewed for oxygen.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infections when 1 of 4 (Licensed Practical Nurse (LPN) A) staff members failed to clean reusable resident care equipment for 1 of 5 residents (Resident #42) and when 1 of 4 (Registered Nurse (RN) B) staff members improperly disposed of used sharps for 1 of 5 residents (Resident #104) reviewed during medication administration.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in 1 of 10 (Resident #18) resident bathrooms on the secured unit for 1 of 14 (Resident #18) residents observed for accident hazards. There were 10 Wandering residents on the secured unit.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 4 (Licensed Practical Nurse (LPN) A and Registered Nurse (RN) E medications were observed unsecured and unattended in 2 of 7 (Memory Care Medication Cart and 300 Hall Medication Cart) medication storage areas.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure safe infection control practices to help prevent the spread of infectious diseases for 2 of 6 (Resident #4 and #44) residents observed during medication administration when 2 of 4 nurses (Registered Nurse (RN) E and Licensed Practical Nurse (LPN) D) failed to disinfect a stethoscope and use a clean syringe after the syringe was contaminated.

Inspectors wroteBased on the National Pressure Injury Advisory Panel 2019 Guidelines, policy review, medical record review, observation, and interview, the facility failed to provide care and services to appropriately identify pressure ulcers/pressure injuries (PU/PIs), to provide services to promote healing, and to promptly notify the physician or practitioner for changes in the right foot PU/PI wound status to reduce the risk for infection for 1 of 4 (Resident #9) sampled residents reviewed for PU/PIs. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide a clean and sanitary environment for 3 of 4 (100-Hall, 200-Hall and 300-Hall) hallways observed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide a safe environment and ensure supervision to prevent neglect for 1 of 3 sampled residents (Resident #36) reviewed for elopement risk. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy when Resident #36, a vulnerable resident with severe cognitive impairment was found 0.9 miles from the facility on a warm summer day. The facility was unaware of the resident's location for approximately 30-45 minutes. Resident #36 was located on the corner of a busy street in an [NAME] area by a facility staff member driving on her lunch break. [...]

Inspectors wroteBased on policy review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for 1 of 3 sampled residents (Resident #36) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy when Resident #36, a vulnerable cognitively impaired resident, exited the facility unsupervised through an unlocked door. Resident #36 was found by a facility staff member driving on her lunch break approximately 0.9 miles from the facility, approximately 30-45 minutes later. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm and impairment or death to a resident. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were followed when 1 of 1 nurses (Licensed Practical Nurse (LPN) #7) failed to perform proper hand hygiene during wound care for 2 of 2 sampled residents (Resident #32 and #43) reviewed during wound care.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure 2 of 18 sampled residents (Resident #12 and #32) or their families were invited to participate in planning their care.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide reasonable accommodations to meet the residents' needs for the use of a call light for 2 of 25 sampled residents (Resident #34 and #38) reviewed.

Inspectors wroteBased on review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 dated October 2019, medical record review, and interview, the facility failed to ensure residents were accurately assessed for nutritional status and falls for 2 of 18 sampled residents (Resident #38 and #55) reviewed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to develop and implement a comprehensive Care Plan for antianxiety and anticoagulant medication and falls for 2 of 18 sampled residents (Resident #63 and #78) reviewed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to follow Physician Orders for treatment of a Urinary Tract Infection for 1 of 2 sampled residents (Resident #8) reviewed with Urinary Tract Infections.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to provide care and services for residents with enteral feeding tubes when 2 of 2 nurses (Licensed Practical Nurse (LPN) #1 and #2) were observed administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube by applying pressure and pushing the medications into the tube without attempting to administer them by gravity and failed to appropriately store the feeding syringe for 1 of 1 sampled residents (Resident #29) observed during PEG medication administration.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to administer pain medications as ordered for 1 of 5 sampled residents (Resident #17) reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to administer medications with a medication error rate less than 5% (percent) when 2 of 4 nurses (Licensed Practical Nurse (LPN) #1 and #4) failed to administer medications as ordered to 2 of 6 sampled residents (Resident #36 and #56) reviewed during medication administration. A total of 3 errors were observed out of 31 opportunities, resulting in a 9.68% error rate.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when unattended and unsecured medications were found in 4 of 146 resident rooms (Resident #12, #29, #38, and #43) and when medications were expired in 1 of 8 medication storage areas (200 Hall Medication Room).

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure dental services were provided for 1 of 1 sampled residents (Resident #32) reviewed.