Cypress Pointe Rehabilitation and Nursing

Inspectors wroteBased on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 45 residents (Resident #95), in the survey sample which constituted harm.

Inspectors wroteBased on information obtained during the Infection Control task, the facility staff lacked documentation of all staff members' COVID-19 information.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for two (2) of 45 residents in the survey sample, Resident #10 and Resident #42.

Inspectors wroteBased on resident and staff interviews and a review of the clinical record, the facility staff failed to provide the necessary activities of daily living (ADLs) for 2 dependent residents (Resident #79 and Resident #10) of the 45 residents in the survey sample.

Inspectors wroteBased on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide services to maintain hearing abilities for 1 of 45 residents (Resident #14), in the survey sample.

Inspectors wroteBased on resident and staff interviews and a review of the clinical record, the facility staff failed to provide appropriate treatment and services to assist Resident #79 to achieve as much bowel and bladder control as possible, for 1 of 45 in the survey sample.

Inspectors wroteBased on resident and staff interviews and a review of facility documents, the facility staff failed to ensure that the binding arbitration agreement was clearly explained to three (3) of 45 residents (Residents #97, 3, and 79) in the survey sample.

Inspectors wroteBased on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to notify the resident's family representative (daughter) of a change in condition for one (1) of 45 residents (Resident #8), a closed record resident in the survey sample.

Inspectors wroteBased on observations, resident and staff interviews, and a review of the clinical records, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 45 residents (Resident #96) a closed record resident in the survey sample. Resident #96 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' diagnoses included non-pressured chronic ulcer of other part of left foot. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. Section M coded resident as having not having a pressure ulcer/injury, scar over a bony prominence. [...]

Inspectors wroteBased on resident and staff interviews and a review of the clinical record, the facility staff failed to review and revise the person-centered care plan as the resident's condition changed for 1 of 45 residents (Resident #79) in the survey sampleThe

Inspectors wroteBased on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure two infected advanced staged wounds on the Left ankle and Left Ischium were treated with antibiotics timely for 1 of 45 residents (Resident #71), in the survey sample. Resident #71 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included: Pressure ulcer of left heel, Pressure ulcer of left Ischium/buttock unstageable, and Muscle weakness. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/29/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. [...]

Inspectors wroteBased on observations and a review of resident dietary tickets, the facility staff failed to serve portions of the planned menu for two (2) of 45 residents (Resident #32 and Resident #64) in the survey sample.

Inspectors wroteBased on information acquired while reviewing infections acquires in the facility and staff interviews the facility staff failed to have a qualified individual to perform the role of an Infection preventionist (IP).

Inspectors wroteBased on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to administer pain medication to a resident who experienced pain and requested pain medication for one (1) of eight (8) residents in the survey sample, Resident #7.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to document administered controlled medication on the medication administration record (MAR) for one (1) of eight (8) residents in the survey sample, Resident #7.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to maintain a complete infection control surveillance program. The facility staff failed to maintain a complete surveillance system with enough data collection to properly track infections.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to conduct COVID-19 testing in a manner consistent with professional standards of practice. The facility staff failed to conduct complete COVID-19 testing during a facility outbreak that began on 6/10/22.

Inspectors wroteBased on staff interview, facility document review, employee record review, and in the course of a complaint investigation, it was determined the facility staff failed to complete criminal background checks on 7 out of 25 employee records reviewed.

Inspectors wroteBased on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to implement their policies for the investigation of an allegation of abuse for one of 43 residents in the survey sample, Resident #26; and failed to implement their policies for the investigation of an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5); and failed to implement their policies for the completion of criminal background checks for 7 of 25 employee record reviews.

Inspectors wrote2. The facility staff failed to develop a comprehensive care plan for treatment and care of (R36's) pressure ulcer. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/10/2022, the resident scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. The physician's order for (R36) DATED 08/06/2022 documented in part, Sacral: Cleanse with wound cleanser, pat dry, apply hydrogel and foam dressing every other day, and prn. Review of the comprehensive care plan for (R36) dated 07/23/2022 failed to evidence documented for care and services for (R36's) sacral pressure ulcer. On 08/04/22 at approximately 11:24 a.m., an interview was conducted with LPN (licensed practical nurse) #5. [...]

Inspectors wrote2. The facility failed to evidence coordination of hospice services with the hospice provider for Resident #6 (R6). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/22, R6 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). R6 was coded as receiving hospice services during the look-back period. A review of R6's clinical record revealed the following provider's order dated 4/22/22: Admit to [name of hospice company]. A review of R6's care plan dated 5/17/22 revealed, in part: Resident admitted to hospice services .Encourage support system of family and friends .Work with [hospice] nursing staff to provide maximum comfort for the resident. [...]

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to administer oxygen in a safe, sanitary manner for 4 of 43 residents in the survey sample, Residents #73, #69, #26, and #38.

Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to maintain a clean deli slicer and store dishware in a clean and sanitary manner in one of one kitchen; and failed to label and date resident food stored in the refrigerator in one of two nourishment rooms in accordance with professional standards for food service safety.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide education and offer the COVID-19 immunization for 4 of 5 residents reviewed during the immunization record reviews, Residents #3 (R3), #73 (R73), #18 (R18) and #42 (R42). The facility staff failed to provide Residents R3, R73, R18 and R42 (or their representatives) education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine, or offer the vaccine.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain an operational call bell system for four of 43 residents in the survey sample, Residents #29 (R29), #46 (R46), #60 (R60), and #36 (R36)

Inspectors wroteBased on staff interview, employee record review and facility documentation review, it was determined that the facility staff failed to ensure that 5 of 5 certified nursing assistants (CNAs) during annual performance reviews received dementia training (CNAs #2, #3, #4, #5 and #6).

Inspectors wroteBased on observation, staff interview, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to notify the physician and/or responsible party (RP) of missed medication and a change in condition for 2 of 43 residents in the survey sample, Resident #427 and #50.

Inspectors wroteBased on staff interview, facility document review, clinical record review, and in the course of a complaint allegation, it was determined the facility staff failed to report to the state agency an allegation of abuse for one of 43 residents in the survey sample, Resident #26 (R26); and failed to report an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5).

Inspectors wroteBased on staff interivew, facility document review, clinical record review and in the course of a complaint investigation, it was detrmined the facility staff failed to investigate an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5).

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff for 2 out of 43 residents in the survey sample that were transferred to the hospital; Residents #27 and #26.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that written RP (responsible party) and/or ombudsman notification was provided for 3 of 43 residents who were transferred to the hospital, Residents #27, #26 and #29.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided to one out of 43 residents in the survey sample who was transferred to the hospital; Residents #27.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for the use of oxygen for Resident #26 (R26).

Inspectors wroteBased on staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, it was determined that the facility staff failed to develop, with the resident or the resident representative, a discharge plan for one of 43 residents in the survey sample, Resident #428. Resident #428's RP (responsible party), was not provided education on insulin administration or wound care. DME (durable medical equipment) was not at resident's home upon her discharge from the facility.

Inspectors wroteBased on observation, staff interview, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to implement interventions to keep a resident safe for one of 43 residents in the survey sample, Resident #34 (R34). R34's care plan called for anti-roll back system to be placed on R34's wheelchair. No anti roll devices were observed on multiple occasions during the survey while R34 was in the wheelchair.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for 3 of 43 residents in the survey sample, Residents #73, #4, and #23.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to store medications in a safe manner on 1 of 2 nursing units, [NAME] Garden Unit. 1. RN #1 left medications on top of a medication cart, unsupervised, on the [NAME] Garden unit. 2. LPN #2 left the medication cart unlocked during medication administration, while it was unsupervised, on the [NAME] Garden unit.

Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to obtain laboratory tests per physician's order for one of 43 residents in the survey sample, Resident #276. The facility staff failed to obtain multiple lab tests per Resident #276's (R276) nephrologist's (kidney doctor) orders.

Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to obtain a diagnostic test per physician's request for one of 43 residents in the survey sample, Resident #276. The facility staff failed to obtain a renal ultrasound (1) per Resident #276's (R276) nephrologist's (kidney doctor) request.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to maintain documentation of grievances. The facility staff failed to evidence documentation of grievances for 2020 and 2021. This was cited as past non-compliance.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to complete and post daily nurse staffing information before the shift. On 08/02/2022 and 08/03/2022 the facility staff failed to post the nurse staffing prior to the beginning of the shift and failed to document the facility's census on 17 of 31 days of July 2022.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow professional standards of practice and document the amount of insulin actually given for three of 37 residents in the survey sample, Resident #42, #19 and #53.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that facility staff failed to apply hair restraints before entering the food preparation area in the facility kitchen. On 11/19/19 at 6:20 PM during the initial tour of the kitchen there were no hair restraints available upon entrance into the kitchen and food prep area. On the floor before entering into the kitchen and food prep area was a yellow and black strip with unreadable lettering. There were staff observed throughout the survey crossing the unreadable yellow and black line on the floor entering the kitchen without hair restraints. In order to get a hairnet you had to enter the kitchen, turn right and go past the food prep area to open a drawer that housed the hair restraints. On 11/20/19 at approximately 11:15 AM a tour of the kitchen was made with the Dietary Director. [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written bed hold notification at the time of an acute transfer to the hospital for one of 37 residents in the survey sample, Resident #42.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to transmit a discharge assessment within the required time frame for two of 37 residents in the survey sample, Residents #1 and #2.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review and clinical record review the facility staff failed to develop a complete comprehensive care plan to include Diabetes Mellitus and that the resident was a smoker, for 1 of 37 residents in the survey sample, Resident #5.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to revise the care plan for one of 37 residents in the survey sample, Resident #4.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to obtain orders for the use of a catheter for one of 37 residents in the survey sample, Resident #83.

Inspectors wroteBased on observation, staff interview, facility documentation review, the facility staff failed to ensure that 1 opened bottle of house stock calcium tablets 500 mcg (micrograms) with the expiration date of 09/2019 was discarded.

Inspectors wroteBased on observation and staff interview the facility staff failed to ensure the garbage storage area was maintained in a sanitary condition.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure an accurate clinical record for one of 37 residents in the survey sample, Resident #19.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to maintain infection control practices during the dining room observation for two of 37 residents, Resident #46 and #73; and failed to practice infection control measures while performing wound care for one of 37 residents, Resident #57.