Cypress Woods Care Center

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure a safe, clean, and sanitary environment for residents when staff allowed four residents' toothbrushes to be stored together in a single cup, resulting in direct contact between the toothbrush heads for Residents #1, #2, #3 and #4. The facility failed to separate residents personal toothbrushes and store them in separate toothbrush cup holders or zip lock bags per DON. This practice created an unsanitary and non homelike environment and failed to protect residents from potential cross contamination. This failure could place residents at risk of cross-contamination. Record review on 01/11/2026 revealed a statement made by the Residents #1 After witnessing horrible conditions such as pest, dirty and unsanitary conditions, such as all residents' toothbrushes kept together in a cup. [...]

Inspectors wroteBased on interview, and record review the facility failed to obtain laboratory services to meet the needs of 1 of 5 residents (Resident #31) reviewed for laboratory services. The facility failed to ensure Resident #31 received lab test that were ordered for lipid panel and thyroid panel to know if the medications of atorvastatin and levothyroxine were at correct levels for administration to resident. This failure could place residents at risk for adverse effects of pain, discomfort, increase side effects, not receiving the therapeutic effects of the medication, and a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 8 of 59 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #8 and Resident #9) reviewed for accidents and supervision. 1. The facility failed to ensure 8 residents were able to evacuate in the event of an emergency due to plywood bolted down to the exterior door that barricaded the exit on Hall A. 2. The facility failed to ensure 8 residents on Hall A had two exits available in an event of an emergency due to the dead-end corridor. An immediate jeopardy (IJ) was identified on 6/4/2024 at 5:37 p.m. The IJ template was provided to the facility on 6/4/2024 at 5:37p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included a fall mat at Resident #1's bedside. The facility failed to implement a comprehensive care plan intervention for Resident #1 which addressed her fall risk which included her bed should have been placed in the lowest position This failures placed the resident at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety and failed to ensure that one of one dish washing machine in the kitchen had a readable hot water gage in 1 of 1 kitchen observed for kitchen sanitation. -The facility failed to ensure that cooking utensils were kept clean and in proper working order. -The facility failed to ensure foods items in the walk-in cooler were properly stored, labeled (missing label identifying items in the bag), and dated (date prepared or date expired). -The facility failed to ensure that expired food products were removed from the walk-in cooler and dry good storage area. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity for 3 of 16 residents (Resident #5, Resident #41, and Resident #47) reviewed for comprehensive assessment. -The facility failed to ensure that assessments accurately reflected Residents #5 and 41's falls. -The facility failed to ensure that Resident # 5 was accurately assessed for her oral cavity. -The facility failed to ensure that Resident #47 was accurately assessed for her falls and oral dental health. These failures could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan describing services (Resident #45 was care planned for thickened liquids while receiving thin liquids) that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 15 residents, (Resident #45) reviewed for care plan revision and completion. Resident #45's care plan was not revised to accurately reflect his current nutritional needs for fluid intake. Resident #45 was care planned for thickened liquids while receiving thin liquids. This failure placed residents at risk of not receiving appropriate or accurate nutritional needs.

Inspectors wroteBased on observation, interviews 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 storage and sanitation in that: Cook D used the facility phone 3 times during meal service without washing her hands afterwards. This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to have an accurate MDS assessment for 3 residents (#26, #50 and #54) out of 24 residents reviewed for accurate MDS assessments in that: 1. The facility did not have Resident #26's pacemaker coded on the MDS. 2. The facility did not have Resident #50's pacemaker coded on the MDS. 3. The facility active diagnosis of heart failure was not coded on his Resident #54's MDS assessment. This deficient practice could affect residents who required assessments at the facility and result in resident needs not being met.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for 3 (Resident's #54, #110 and #113) out of 3 residents reviewed for baseline care plans in that: 1. Resident #54's heart failure and cardiac issues were not addressed in his baseline care plan. 2. Resident #110's code status was not addressed in his baseline care plan. 3. Resident #113's code status was not addressed in her baseline care plan. This deficient practice could affect newly admitted residents and could result in inaccurate care provided.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights for 3 residents (Resident #21, Resident #35 and Resident #48) of 8 residents reviewed for comprehensive care plans in that: 1. Resident #35's 1/2 side rails were not reflected on her comprehensive plan of care. 2. Facility failed to ensure Resident #48's comprehensive care plan addressed her pace maker. 3. Resident #54's comprehensive care plan did not reflect his heart failure or cardiac status. This deficient practice could affect residents with person-centered comprehensive care plans and could result in missed care required.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 4 residents (#21, #31, #44, #48) out of 20 residents reviewed for comprehensive care plan revision in that: 1. Facility failed to ensure Resident #21's comprehensive care plan was revised after her Significant Change MDS assessment to reflect here DNR status. 2. Facility failed to ensure Resident #31's comprehensive care plan was revised to address the change in code status from DNR (Do Not Resuscitate) to Full code. 3. Facility failed to ensure Resident #44's comprehensive care plan was revised to address the change in code status from Full code to DNR (Do Not Resuscitate). 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for 1 of 1 meal (dinner) observed, in that: Cook D pureed egg salad and macaroni salad with water for the lunch meal on 09/21/22, diluting the nutritive value. This failure could place residents who receive pureed meals from the kitchen at risk for malnutrition and/or weight loss due to decreased nutritive value of the food.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 resident (#46) of 2 residents reviewed for catheter care in that: CNA A did not clean Resident #46's indwelling urinary catheter tubing when she performed catheter care for the resident. CNA A raised Resident #46's indwelling urinary catheter bag filled with urine above her bladder and to the other side of the bed when she assisted the LVN B with Resident #46's wound care. These deficient practices could affect residents with indwelling urinary catheters and could result in urinary tract infections.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 residents (#56 and #111) of 6 residents reviewed for oxygen therapy in that: 1. Resident #56's oxygen tubing was not dated and his nebulizer mask was not in a bag. 2. Resident #111's oxygen tubing was not dated and his nasal cannula was not bagged when he was not in his room. This deficient practice could affect residents on oxygen therapy and could result in respiratory compromise.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assessed and had consents for bed rails for 1 of 1 resident (#35) reviewed for bed rails in that: Resident #35 did not have an assessment or informed consent for the use of bed rails. This deficient practice could affect residents who utilized some type of bed rails in the facility and could place the residents at risk for potential and avoidable injuries.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a therapeutic diet, in the appropriate form as prescribed by a physician for 1 of 20 residents (Resident #48) observed for therapeutic diets. The facility failed to provide Resident #48 a pureed diet, as ordered by the physician. This failure could affect residents with physician orders for therapeutic diets and could result in consumption of inappropriate textured food items which could cause choking or aspiration and a decline in health.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 2 residents (#21 and #50) of 24 residents reviewed for code status in that: 1. Resident #21 did not have a physician's order for her code status. 2. Resident #50 did not have a physician's order for a pacemaker 1. Review of Resident #21's electronic face sheet revealed she was admitted to the facility on [DATE] with diagnoses of cellulitis of right and left lower limbs (swelling and inflammation of lower limbs), repeated falls, atherosclerotic heart disease (plaque in heart arteries obstructing blood flow) and major depressive disorder (mood changes). [...]

Inspectors wroteBased on observations, interviews, and record reviews, 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 disease and infections for 1 resident (#46) of 2 residents reviewed for wound care and catheter care in that: CNA A did not sanitize her hands when she changed her gloves after taking off the dirty brief when she performed catheter care for Resident #46. LVN B did not sanitize her hands when she changed her gloves after taking off the dirty dressing, when she performed wound care for Resident #46. These deficient practices could affect residents with wound treatments and incontinent care and could result in cross contamination.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to conduct an inspection of all bed frames, mattresses, and bed rails for 1 resident (#21) of 1 resident reviewed for bedrails in that: Resident #21 had 1/2 length side rails on her bed which had not been inspected or assessed. This deficient practice could affect residents who have beds with siderails and could result in entrapment.