Cypress Springs Wellness & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's environment remained free of accidents and hazards for 1 of 1 resident (Resident #2) reviewed for accident hazards. The facility failed to ensure a safe transfer for Resident #2 when CNA C and CNA D performed a transfer without utilizing a gait belt on 07/06/2026. This failure could place residents at risk of injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for respiratory care and services. The facility failed to properly store Resident #1's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 1 of 1 personal linen cart reviewed for infection control practices. The facility failed to ensure clean laundry was transported to prevent the spread of infection. These failures could place residents and staff at risk for cross contamination and the spread of infection.

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 1 of 3 staff (LVN A) infection control. The facility failed to ensure LVN A wore a gown when providing wound care to Resident #1 on 6/2/26. This failure could place residents at risk for MDROs, cross-contamination, and spread of infection. Findings Include:During an observation on 6/2/26 at 8:50 a.m. EBP signage was observed on the wall next to Resident #1's door to her room. During an observation on 6/2/26 at 9:20 a.m., LVN A performed wound care on Resident #1. LVN A explained the procedure to Resident #1, brought supplies in the room, performed hand hygiene and put on clean gloves. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. [...]

Inspectors wroteBased on observation, interview and record review he facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage of resident's food and beverage items for 3 of 3 Residents (Resident #2, Resident #3 and Resident #4) reviewed for personal food in that: The facility failed to implement the food policy related to personal refrigerators and monitor the temperatures for in-room personal refrigerators and freezers daily for Resident #2, Resident #3, and Resident #4. This deficient practice could place residents who had personal in-room refrigerators at risk of food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's nebulizer (a device used to deliver medicine to the lungs) mask was stored properly. This failure could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service in that: The facility failed to keep personal food or beverage items out of the walk-in cooler. This failure could place residents who received meals from the kitchen at risk of food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 3 of 13 residents (Resident #2, Resident #29, and Resident #188) reviewed for laboratory services. The facility failed to obtain Resident #2's CMP (lab test that provides an overall picture of your body's chemical balance and metabolism, and can help diagnose, screen for, or monitor health conditions or medication side effects) as ordered. The facility failed to obtain Resident #29's CBC (used to monitor and diagnose medical conditions, check the health of the immune system, and detect disorders including infections, anemia, and blood cancer) and CMP as ordered. [...]

Inspectors wroteBased on interview and record review the facility failed to promptly notify and follow-up with the ordering physician regarding laboratory results outside of clinical reference range for 1of 20 residents (Resident #25) reviewed for laboratory services. The facility failed to respond to Resident #25's physician when he questioned Resident #25's Keppra (used to control seizures) dosage on 03/31/25. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level.

Inspectors wroteBased on interview and record review, the facility failed to make a comprehensive assessment of each residents' needs, strengths, goals, life history, and preferences within 14 calendar days after admission for 1 of 13 residents (Resident #10) reviewed for accuracy of assessments. The facility failed to complete Resident #10's admission MDS assessment, with an ARD of 03/11/2025, within 14 days of admission. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 2 residents (Residents #23 and Resident #24) reviewed for care plans. 1. The facility failed to ensure Resident #23 had her fall mat in place while in bed. 2. The facility failed to ensure Resident #24's care plan included the use of the antidepressant medication. These failures could have placed residents at risk for not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents environment remained as free of accident hazards as was possible for 1 of 13 residents (Resident #7) reviewed for accident hazards. The facility failed to ensure the meyer's cleaner in Resident #7's room was properly stored. These failures could place residents at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 13 residents reviewed in sample (Resident #7 and Resident #11). 1. The facility failed to ensure Resident #7 did not have prescribed wound cleanser and non-prescribed buttocks powder left at bedside on the dresser. 2. The facility failed to ensure Resident #11 did not have artificial tears on his bedside table. These failures could place residents at risk of injury.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Residents #25) reviewed for hospice services. The facility failed to obtain Resident #25's most recent updated hospice plan of care and hospice nursing visit notes. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wrote2. Record review of Resident #7's face sheet dated 06/10/25 indicted he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses heart failure(chronic disease in which the heart does not pump as it should), diabetes (disease causing high or low blood sugar levels), glaucoma (disease causing poor vision), kidney failure, anxiety, and high blood pressure. Record review of Resident #7's quarterly MDS dated [DATE] indicated he usually understood others and was able to make himself understood. The MDS also indicate he had a BIMS score of 11 which meant he had moderate cognitive impairment. The MDS also indicated Resident #7 had a foley catheter and skin treatments. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent, neglect, and abuse of residents, for 1 of 7 residents (Resident #1) reviewed for abuse. 1. Resident #1 alleged CNA B was rough, while providing incontinent care as pushed her left shoulder causing her to almost hit her head on the rail during care. CNA A witnessed the alleged abuse and failed to report timely to the abuse coordinator on 03/09/2025. 2. The facility did not ensure the ADON and DON notified the abuse coordinator of an allegation of abuse reported by CNA C on 3/09/2025 at 6:07 a.m. via a text message concerning Resident #1. The Abuse coordinator was made aware of the ADON and DON's knowledge of the abuse allegation on 4/10/2025 by the surveyor. 3. [...]

Inspectors wroteBased on interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 resident (Resident #1) reviewed for resident rights. 1. The facility did not ensure CNA B removed her earbuds prior to providing care to Resident #1. 2. The facility did not ensure CNA D spoke in a manner of respect to Resident #1. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

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 dietary services. 1. The dietary staff [NAME] K failed to maintain safe temperatures at or above 135 degrees Fahrenheit for hot foods. 2. The facility failed to ensure staff did not enter the kitchen without performing hand hygiene or wearing hair restraints. These failures could place residents at risk for foodborne illness and contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to 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 6 of 16 residents (Resident #4, Resident #133, Resident #14, Resident #13, Resident #21, Resident #6) reviewed for infection control practices. 1. The facility failed to ensure CNA L performed hand hygiene and changed gloves while providing incontinent care for Resident #4. 2. The facility failed to ensure LVN A cleaned the electronic wrist blood pressure monitor after she checked Resident #13's blood pressure, before checking Resident #14's blood pressure. 3. The facility failed to ensure LVN A performed hand hygiene after administering medications to Resident #13. 4. [...]

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 receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 16 residents (Resident #24) reviewed for ADLs. The facility failed to provide Resident #24 assistance with removal of her facial hair. These failures could place residents at risk of not receiving services and care, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in a locked compartment, only accessible by authorized personnel for 1 of 1 medication carts (Medication Cart) reviewed for storage of medications. The facility failed to ensure the Medication Cart was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for not receiving drugs and biologicals as needed, misuse of medications, and a drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 14 residents reviewed for palatable food. (Residents #1, Resident #6, Resident #12) The facility failed to provide palatable food served at an appetizing temperature to Residents #1, Resident #6, Resident #12 who complained the food was served cold. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to refer residents with a newly evident or possible serious mental disorder for a level II assessment for 2 of 5 residents reviewed for PASRR. (Resident #7 and Resident #15) The facility failed to refer Resident #7 for a PASRR level II assessment when he was diagnosed with a new mental illness. The facility failed to refer Resident #15 for the PASRR Level II assessment, when Resident #15's PASRR Level I Screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents with positive PASRR at risk of not receiving services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to 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 within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for 1 of 5 residents reviewed for new admissions (Resident #28) The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #28. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 14 residents reviewed for respiratory care. (Resident #12 and Resident #18). The facility failed to properly store Resident #12 and Resident #18's respiratory equipment. The facility failed to change the oxygen humidifier bottle for Resident #12 in a timely manner. These failures could place residents at risk of respiratory infections.