Cypress Point-Skilled Nursing by Americare

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 65. Review of the facility's policy titled, Food Storage, dated 2011, showed:- Label all food items held for longer than 24 hours;- The label must include the name of the food and the date by which it should be sold, consumed, or discarded; - Store leftover contents of cans of prepared food in a clean, sanitized container with a proper and secure cover. The new container shall be labeled with the name of the food item and the original expiration date. The facility did not provide a policy addressing the ice machine, kitchen floor cleaning, dented cans, and use of trash cans.1. Observations on 09/15/25 at 9: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 65. The facility did not provide a policy for a homelike environment.1. Observations on 09/15/25 at 9:34 A.M., and 2:20 P.M., 09/16/25 at 2:10 P.M., 09/17/25 at 3:24 P.M., and 09/18/25 at 9:02 A.M., of the kitchen's ice machine area showed: - A strip of baseboard trim unattached from the wall on the bottom right side near the ice machine. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate diagnosis for the use of an antipsychotic (medication that affect a person's mental state) medication for one resident (Resident #4) and failed to monitor the drug regimen for an unnecessary medication by not ensuring an as needed (PRN) psychotropic (medication that alters the levels of chemicals in the brain that influence mood, behavior, and perception) medication order was limited to 14 days unless a specific duration and clinical rationale was provided for one resident (Resident #8) out of five sampled residents. The facility census was 65. Review of the facility's policy titled, Psychotropic Medication Use, undated, showed:- Psychotropic medications are divided into four broad categories: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately reconciled for one resident (Resident #37) of out of 23 sampled residents. The facility also failed to ensure vials of tuberculin (the solution used to administer the test for tuberculosis (TB - an infectious lung disease)) were dated when opened. The facility census was 65. The facility did not provide a policy regarding the narcotic reconciliation. The facility did not provide a policy regarding dating of medications when opened. 1. Review Resident #37's medical record showed:- An admission date of 12/16/24;- An order for lorazepam (an antianxiety medication) 0.5 milliliters (ml) every 8 hours for agitation related to anxiety, dated 04/23/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) when staff accessed and administered medications through a central venous access device (CVAD - a thin, soft, flexible tube that is placed in a vein that leads to the heart) and during personal care for one resident (Resident #33) out of one sampled resident. The facility census was 65. Review of the facility's policy, titled, Enhanced Barrier Precautions, dated 2024 showed:- An order for EBP will be obtained for residents with any of the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct inspections of all bed frames, mattresses, and side rails as a part of a regular maintenance program for three residents (Residents #8, #11, and #28) out of three sampled residents. The facility census was 65. Review of the facility's policy titled, Side Rail Inspection, undated, showed:- Side rails on resident beds must be inspected regularly to ensure safety, proper function, and compliance with regulatory standards. Faulty or unsafe side rails pose a risk of injury, entrapment, or falls and must be addressed immediately;- Routine inspection frequency: Weekly: Visual inspections by nursing staff during bed checks, Monthly: Detailed inspection by maintenance or designate safety personnel, as needed (PRN): [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to ensure the safety of one resident (Resident #1), when staff assisted the resident to the toilet and did not check on the resident for approximately nine hours. Staff found the resident lying on the bathroom floor on top of his/her wheelchair cushion with his/her hand completely de-gloved (stripped of the skin), an open fractured wrist (bone broken and protruding through the skin), and a laceration to his/her forehead. The facility census was 60. The Administrator was notified on 03/03/25 at 1:55 P.M. of an Immediate Jeopardy (IJ) which began on 02/21/25. The IJ was removed on 03/03/25 as confirmed by surveyor onsite verification. Record review of the facility policy titled Restorative Sleep Program, dated 09/05/2018, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and follow an individualized comprehensive care plan with specific interventions for two residents (Resident #12 and #63) out of 17 sampled residents. The facility's census was 68. Review of the facility's policy titled, Care Plan Policy, undated, showed: - The purpose of the policy is to set out the values and framework within which the individuals care plan is completed and updated; - Care planning is critical to the quality of service in any care home. It is the means by which the values of the home are translated into specific objectives for each individual who live there; - The care plan should be the means by which the identified needs and wishes of the individual are recorded. It ensures that care is offered consistently by well-informed staff, aware of the individual care needs. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and document a wound for one resident (Resident #12) out of two sampled residents. The facility's census was 68. Review of the facility policy titled, Skin Assessment, not dated, showed: - A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and as needed by a nurse/certified nurse assistant (CNA) while performing personal care/shower. Any changes in skin assessment will be reported to the charge nurse for further evaluation. The assessment may also be performed after a change of condition or after any newly identified pressure injury; - Documentation of skin assessment: include date and time of the assessment, your name, and position title; document observations (e.g. [...]

Inspectors wroteBased on interview and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 68. Review of the facility's policy titled, Refrigerator/Freezer Temperatures, dated 2011, showed: - In order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators in nourishment rooms; - Dining Services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperature report logs daily, during each shift. Review of the facility's policy titled, Dishwashing: Machine, dated 2011, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow enhanced barrier precautions (EBP) for four residents (Residents #12, #13, #35 and #56) out of four sampled residents during care. The facility census was 68. Review of the facility's policy titled, EBP, undated, showed: - An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters (a tube inserted into the bladder to drain urine), feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with multi-drug resistant organism (MDRO); - High-contact resident care activities include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 68. Review of the facility's policy titled, Resident Environmental Quality, revised February 2023, showed: - It is the policy of the facility to be designed, constructed, equipped and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public; - Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dignity of two residents (Resident #36 and #55) out of two sampled residents with a properly covered urinary catheter bag (a bag for collecting urine from a tube in the bladder). The facility census was 63. Review of the facility's policy titled, Resident Rights, not dated, showed: - The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights and the responsibility of the facility to properly care for its residents; - The resident has the right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan upon admission with specific interventions for one sampled resident (Resident #167) out of 5 sampled residents. The facility census was 63. Review of the facility's policy titled, Baseline Care Plan, not dated, showed: - The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; - The baseline care plan will be developed within 48 hours of a resident's admission and include the healthcare information necessary to properly care for a resident; - The baseline care plan will be placed in the resident's closet door. Review of Resident #167's medical record showed: - An admission date of 06/12/23; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an infection control program and a risk management process specific to Legionella disease (a serious type of pneumonia caused by legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility also failed to maintain adequate infection control practices to prevent the transmission of infection when staff demonstrated poor hand hygiene for four residents (Resident #12, #14, #24, and #216) out of 4 sampled residents. The facility's census was 63. 1. Review of the facility's policy titled, Legionella Risk Management, undated, showed: - The purpose of this policy is to ensure that as far as possible, all users of this facility are protected from the incidence of Legionnaire's disease; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of light fixtures. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 63. Review of the facility's policy titled, Resident Rights, not dated, showed: - The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents; - The resident has the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. [...]