Cypress Healthcare and Rehabilitation Center

Inspectors wroteBased on, interview, and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 8 of 8 months (October 2025-May 2026) of Resident Council minutes reviewed. The facility failed to ensure all grievances that arose in the Resident Council meetings from October 2025 to May 2026 were resolved. This failure placed residents at risk of not controlling their own lives and home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment for 2 of 4 resident halls (100-hall and 500-hall) reviewed for environment. The facility failed to ensure the carpet in the 100-hall and 500- hall was clean and free of foul odors. This failure placed residents at risk of diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 13 of 17 residents (Residents #85, 67, 72, 60, 51, 36, 24, 22, 16, 8, 52, 63, and 31) reviewed for quality of life. Residents #85, 67, 72, 60, 51, 36, 24, 22, and 16 were observed in the television room for the entire mornings of 06/23/2026, 06/24/2026, and 06/25/2026, without any activities offered beyond sitting in their wheelchairs and watching television. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure food was properly labeled and dated in the facility kitchen refrigerator on 06/23/2026. This deficient practice could place residents who ate food served from the kitchen at risk for health complications and foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 13 residents (Residents #16, #22, #31, #8, #67, and #72) reviewed for care plans. The facility failed to ensure that Residents #16, #22, #31, #8, #67, and #72 had care planning for activity preferences. This failure placed residents at risk of not having recreational interventions in their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 8 residents (Residents #13 and #52) reviewed for ADL care. The facility failed to ensure Resident #13 was offered nail care and showers in accordance with his shower schedule and Resident #52 was offered showers according to her shower schedule or assisted with changing her clothes from 06/23/2026 to 06/25/2026. This failure placed residents at risk of skin problems, body odor, and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 4 of 6 residents (Resident #5, Resident #41, Resident #53, and Resident 76) reviewed for infection control. RN A failed to cleanse the blood pressure cuff after use on resident #53 and prior to use on Resident #41 during an observation of medication pass on 06/24/2026 at 8:48 a.m. [...]

Inspectors wroteBased on observation, interviews, and reviews, the facility failed to ensure the resident's right to secure and confidential personal and medical records for Resident #1. The facility failed to ensure the privacy of the unknown resident by not locking the laptop screen, so the resident's information could not be seen by someone walking by. This failure put residents at risk for confidential health information exposure, psychosocial harm, and decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 9 residents (Resident #1 and Resident #2) reviewed for resident rights. The facility failed to ensure CNA D communicated respectfully to Resident #1 and #2 when removing their food trays and answering call lights. This failure could place residents at risk of feeling not being valued or cause psychosocial harm and emotional distress.

Inspectors wroteBased on interviews and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #1) of 4 residents reviewed for physician notification, in that: The facility failed to notify Resident #1's provider of medication refusals for insulin from 06/01/2025 through 06/19/2025 and Pioglitazone (for type 2 diabetes) on 06/01/2025, 06/07/2025, 06/08/2025, 06/14/2025, and 06/15/2025. This failure could result in decreased continuity of care, and a delay in needed treatment and services.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure [NAME] J were practicing proper hand hygiene while preparing foods. The facility failed to ensure DM were practicing proper hand hygiene as he entered and exited the kitchen. The facility failed to check produce for quality prior to delivery. The facility failed to ensure food service employees have received training related to dishwasher sanitation. The facility failed to ensure record keeping of dishwasher sanitation checks. The facility failed to keep refrigerated foods tightly wrapped or packaged. The facility failed to label and date all refrigerator and freezer items. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 18 residents (Resident #23, Resident #30, Resident #33 and Resident #82) reviewed for resident rights an dignity. The facility failed to ensure that Resident #23 was assisted with feeding when her meal tray was delivered to the assisted dining room. The facility failed to ensure LVN A and MAIN knocked on Resident #30, Resident #33 and Resident #82's doors when going into the residents' rooms. These failures could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. [...]

Inspectors wroteBased on observation , interview and record review the facility failed to ensure residents were provided with a private space, and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for residents' monthly council meetings and the confidential resident group meeting during the survey for 8 of 8 residents reviewed for confidential resident council meeting. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Include: Observation on 04/15/2025 at 10:35 AM, revealed staff walked in on the resident council meeting, and the residents told the staff they were having a meeting . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rights for personal privacy for 3 of 8 residents (Resident #75, Resident #39, and Resident #26) reviewed for resident rights. The facility failed to ensure Resident #75, Resident #39, and Resident #26 were provided privacy and confidentiality when personal care and treatment signs were hung up in their rooms. The failure could place residents at risk of feeling like their privacy is being invaded or the facility is not their home.

Inspectors wroteBased on observation and interview he facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 5 (400 and 500 halls) observed for housekeeping and maintenance services. The facility failed to ensure there were no continuous foul odor on 400 and 500 halls. This deficient practice could place residents at risk of living in an unclean and unsanitary environment and result in feelings of dissatisfaction.

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 for 3 of 3 (Resident #22, Resident #33 and Resident #71) residents, 2 of 2 medication carts (400-hall and 500-hall), and 1 of 1 medication storage room reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #33 took their medication prior to LVN A leaving the room. 2. The facility failed to ensure expired medications and supplies were removed from the 400-hall and 500-hall medication carts and the medication storage room. These failures could place residents at risk for not receiving a therapeutic dosage or another resident taking medications that were not administered to them.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store, label, and/or secure medications and biologicals for 2 of 2 medication carts and 1 of 1 medication storage room reviewed for drug storage. 1. The facility failed to ensure the medication cart for 500 hall was locked when unattended by LVN A on [DATE] at 9:04 AM. 2. The facility failed to ensure glucose control solution was dated with an opened-on date for the 500-hall medication cart. 3. The facility failed to ensure medication were secured in their original packaging. The medication cart for 400-hall had three and a half loose pills. The medication cart for 500-hall had one loose pill. 4. The facility failed to ensure medications that required a prescription were labeled with the appropriate information including the resident's name in the medication storage room and the 500-hall medication cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve a menu to the meet the nutritional needs of residents in accordance with established national guidelines including a subsitution for the main entree for one of one menu reviewed. The facility failed to document resident acceptance or refusal of meal substitutions as per the facility policy. These failures could decrease intake and cause weight loss and functional decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen. The facility failed to ensure [NAME] L were preparing meals within two hours or less of meal service. The facility failed to ensure regular diet and puree test trays rendered a proper serving temperature and had flavor. These failures could compromise and destroy nutritive value of food and prevent residents who ate food from the kitchen at risk of recovery from illness or injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #18) reviewed for ADL care. The facility failed to ensure Resident #18 was provided fingernail care. This failure could place residents at risk for not receiving adequate care and services to prevent infection, injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve each resident receives and the facility provides food prepared in a form to meet individual needs for one of one pureed food preparation. The facility failed to ensure [NAME] L prepared puree foods with adequate and appropriate liquids. These failures could result in choking hazards, decreased nutrient intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for four (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of six resident rooms reviewed for a clean and homelike environment. The facility failed to ensure Rooms #1, #2, #3, and #4 did not have floors and bedside tables that were not caked with food particles and debris and did not have bags of soiled briefs left in them. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to extend to the resident representative the right to make decisions on behalf of the resident for one (Resident #1) of four residents reviewed for resident representative rights. The facility failed to obtain consent by Resident #1's RP before administering the COVID-19 vaccine. This failure placed residents at risk of denying the resident through the resident representative their wishes and preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments inaccessible to unauthorized staff, visitors, and residents for 2 of 4 residents (Resident #1 and Resident #2) reviewed for medication storage. The facility failed to ensure Resident #1 and Resident #2 did not have medications stored at the bedside. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 2 of 4 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #1 had an order for vapor rub and Chloraseptic throat lozenges. The facility failed to ensure Resident #2 had an order for Triad Hydrophilic wound dressing. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to protect Resident #1 from physical and emotional abuse when CNA A forcefully dragged her to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of four residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement the facility abuse policy when they failed to protect Resident #1 from physical and emotional abuse when CNA A forcefully dragged her to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported to the facility Administrator immediately but no later than 2 hours for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to notify their Abuse and Neglect Coordinator (The ADM) within 2 hours when CNA A forcefully dragged Resident #1 to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to, in response to allegations of abuse, neglect or mistreatment, have evidence that all alleged violations were thoroughly investigated for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to investigate an allegation of abuse when CNA A forcefully dragged Resident #1 to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed for qualifications of activity personnel. The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 4 of 4 residents (Residents #3, #46, #47 and #77) reviewed for respiratory care. 1. The facility failed to ensure the filter in Resident #3's oxygen concentrator was not dirty and the water reservoir attached to oxygen concentrator was not empty and replaced in accordance with the facility's changing schedule. 2. The facility failed to ensure Resident #46 did had handheld nebulizer that was bagged and dated. 3. The facility failed to ensure Resident #47's handheld nebulizer was replaced in accordance with the facility's changing schedule. 4. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 6 of 6 residents (Residents #22, #51, #72, #76, #79 and #248) reviewed for food and nutrition services. The facility failed to ensure food prepared for residents who received a pureed diet was in the proper consistency. This deficient practice could place residents who received pureed meals at risk of dissatisfaction, poor intake, choking, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. There were three opened bags of shredded Mozzarella cheese in the walk-in cooler past their use-by date. 2. There were three containers of sour cream in the walk-in cooler past their use-by date. 3. There was a plastic bag of salad mix in the walk-in cooler that contained pieces that were brown. 4. There was a plastic bag of ground food in walk-in cooler that did not have a label identifying the food or the use-by date. 5. There was a bag of pork patties that was open in the walk-in freezer. 6. There was a bag of spaghetti in the dry storage room that was open not properly sealed. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for one of one facility reviewed for personal food policy. The facility failed to ensure the policy regarding use and storage of food brought to residents and family and visitors addressed: Ensuring facility staff assists the resident in accessing and consuming the food if the resident is unable to do so on his or her own; responsibility for storing food brought in by family/visitors in a way separate or easily distinguishable from facility food; and the responsibility to help family and visitors understand safe food handling practices. The facility also failed to provide this policy to family/and or visitors who brought food to residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and comfortable living environment in 1 (Resident Hall 100 Shower Room) of 3 shower rooms reviewed, in that: The Resident Hall 100 Shower Room contained razors and hazardous cleaning materials which were not secured. This deficient practice could result in injury for residents who come into contact with sharp implements or hazardous materials.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accomidation of residents and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 1 (Resident #71) reviewed for cal light. The facility failed to ensure Resident #71 call light was placed with in reach , it was placed on the floor. This failure could place residents at risk of not acheiving independent functioning , dignity , and well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal medical records for personal privacy and confidentiality of residents' personal privacy and medical records for 1 of 15 residents (Resident #38) reviewed for residents rights. The facility failed to ensure LVN M closed the door to provide privacy for Resident #38 while adminstering insulin. This deficent practice could place residents at risk of loss of privacy and dignity and decreased quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 29 residents (Resident #88) reviewed for care plans. The facility failed to develop a care plan to address Resident #88's smoking behavior. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was able to carry out activities of daily living and received the necessary services to maintain good nutrition , grooming , personal and oral hygiene for 1 of 15 (Resident #299) reviewed for ADLs, in that: The facility failed to ensure Resident #299 received grooming for her facial hair. This failure could place residents at risk for embarrassment, decreased self-esteem or decrease quality of life at risk for embarrassment and or decreased self-esteem or decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 of 2 meals reviewed for food and nutrition services: 1. The facility failed to ensure Resident #79 received pureed taco soup with her lunch meal on 03/21/2024. 2. The facility failed to ensure Resident #62 received health shakes with her lunch meal on 03/22/2024. These failures could place residents at risk for dissatisfaction, poor intake, weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for one of 8 residents (Resident #62) reviewed for food and nutrition services. The facility failed to ensure Resident #62 had a physician's order for a pureed diet. The resident was prescribed a regular diet and was provided a pureed diet. This deficient practice could place residents who are provided a modified texture diet at risk poor intake, and weight loss and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices , medical records were maintained on each resident that were accurately documented for 1 of 4 residents ( Resident #97 ) reviewed for accuracy of medical records. The facility failed to ensure documentation of assessments for Resident #97 was stopped after the resident was discharged from the facility on 1/05/24, LVN N continued to document assessments for 1/7/24 and 1/8/24 This failure could place residents at risk of receiving improper care. Findiings include : Record review of Resident #97 face sheet undated revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: [...]

Inspectors wroteBased on observations interview, and record review, the facility failed to provide adequate supervision and assistive devices and ensure the resident environment remained as free of accident and hazards as possible for one (Resident #1) of four residents reviewed for accidents and hazards, in that: The facility failed to ensure transportation was available for Resident #1's dialysis appointment on 01/10/24. While being pushed to the center, her wheelchair fell over causing her to fall out of the wheelchair resulting in a tibia fracture to her right leg. The noncompliance began on 01/10/2024 and ended on 01/11/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of experiencing pain, injuries, a decreased quality of life, and hospitalization.

Inspectors wroteBased on interview and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of three residents reviewed for accurate clinical records, in that: The facility failed to ensure Resident #1's assessments that were conducted after a fall on 01/10/24 were documented in her EMR. This deficient practice could result in errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one of ten residents (Resident #1) reviewed for notification of change. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of fourteen residents (Resident #1) reviewed for falls and supervision. The facility failed to prevent Resident #1 from falling again on [DATE] after an initial fall on [DATE]. She sustained two subdural hematomas, required intubation (mechanical breathing), and underwent two craniotomies (surgical operation on skull) and died on [DATE]. This failure resulted in the identification of an IJ on [DATE] at 02:05 PM. IJ template was provided to the facility on [DATE] at 02:07 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care including but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident needs for one of ten residents (Resident #1) reviewed for assessment of change in condition. The facility failed to ensure Resident #1 received timely intervention following assessment when she slept for 25 hours after an unwitnessed fall, and she required intubation and two craniotomies (a surgical procedure that involves the removal of a part of the bone from the skull or cranium to expose the brain) because of injuries sustained. This failure resulted in the identification of an IJ on 09/06/23 at 05: [...]