Park Manor of Cypress Station

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 9 residents (Resident #1) reviewed for abuse. Resident #2 was physically abusive to Resident #1 on 9/26/25 when he punched him with a closed fist in the face. These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 2 of 9 residents (Residents #1 and #2) reviewed for abuse. The facility failed to implement written policies regarding prevention of abuse when Resident #2 was physically abusive to Resident #1 on 9/26/25 when he punched him with a closed fist in the face. The facility failed to implement written policies regarding abuse prevention and protection when Resident #2 was moved to a new room on 3/11/26 placing Resident #1 and Resident #2 in close proximity to each other after Resident #2 assaulted Resident #1 on 9/26/25. This failure placed residents at risk of abuse, mental anguish and fearfulness.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's nursing, mental and psychosocial needs for 1 of 9 residents (Resident #2) reviewed for comprehensive care plans in that: Resident #2's care plan for physical behaviors was not implemented when he physically abused Resident #3 on 8/8/25 and physically abused Resident #1 on 9/26/25. Resident #2's care plan intervention was to analyze the circumstances and triggers after incidents of physical behaviors. Nursing staff were unaware of circumstances and triggers that could cause Resident #2 to physically abuse other residents. These failures placed residents at risk of not having their behavioral needs met, which could lead to abuse and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision for 3 of 4 residents (CR #1, Resident#2, and Resident #3) reviewed for accidents and supervision. -CR #1 walked out of the facility unattended with a wander guard (device designed to prevent wandering in elderly) and was missing for approximately 1 hour and 9 minutes on 07/20/2024 and was located nearby an apartment complex. -The facility failed to ensure that Resident#2 had orders in place to monitor placement and functioning of a wanderguard from 07/23/2023-06/10/2025. -The facility failed to ensure that Resident#3 had orders in place to monitor placement and functioning of a wanderguard from 03/24/2025-06/10/2025. An Immediate Jeopardy (IJ) was identified on 06/11/2025. The IJ template was provided to the facility on [DATE] 5:43 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that it was free of a medication error rate of below 5 percent (%) or greater. The facility had a medication error rate of 22%, based on 8 out of 37 opportunities, which involved 3 of 6 residents (Resident #72, Resident # 23 and Resident #506) and 2 of 3 staff (MA B and LVN M) reviewed for medication administration errors. MA B administered Calcium Carbonate(used as an antacid to relieve heartburn, acid indigestion and upset stomach), Diphenoxylate/atropine 2.5 mg, and Dicyclomine 40 mg (drug used to treat irritable bowel syndrome) more than 2 hours and 45 minutes after the scheduled time to Resident #72 on 6/10/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #9 and Resident #90) reviewed for incontinent care. -The facility failed to ensure CNA A cleaned Resident #9 properly during incontinent care on 6/10/25. -The facility failed to ensure CNA G cleaned Resident # 90's indwelling Foley catheter properly and followed proper hand hygiene during incontinent care on 6/11/25. -Resident #90 did not have a STATLOCK to secure the Foley catheter. These failures could place residents at risk for pain, infection, injury, and hospitalization.

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 drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Resident #72 and Resident #23) reviewed for drug administration in that: - Resident #72's medication Calcium Carbonate(used as an antacid to relieve heartburn, acid indigestion and upset stomach) was provided 2 hours and 45 minutes late on 06/10/2025. - Resident#72's medication Diphenoxylate/atropine 2.5 mg (to treat severe diarrhea) was provided 2 hours and 45 minutes late on 06/10/2025. - Resident #72's medication Dicyclomine 40 mg (drug used to treat irritable bowel syndrome) was provided 2 hours 45 minutes late on 06/10/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #506) reviewed for significant medication errors. LVN M failed to administer Clopidogrel (Plavix is an antiplatelet drug you can take to prevent blood clots) to Resident #23 as ordered by the physician. This failure could result in increased side effects and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store, label, and/or secure medications and biologicals for 1 of 3 medication carts (400 hall medication cart) and 1 of 1 medication storage room reviewed for drug storage. 1. The facility failed to ensure medications that required a prescription were labeled with the appropriate information including open date in the medication room in the refrigerator. 2. 400-hall medication cart had medication open not dated. These failures could place residents at risk of not receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 2 residents (Resident #9 and Resident #90) and 2 of 2 staff (CNA A and CNA J) reviewed for incontinent care and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #71) of 28 residents reviewed for infection control. The facility failed to ensure CNA A washed or sanitized her hands after doffing (taking off) dirty gloves after providing incontinent care on 6/10/25 for Resident #9. The facility failed to ensure CNA J washed or sanitized her hands after doffing (taking off) dirty gloves after providing incontinent care on 6/11/25 for Resident #90. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. -The facility did not ensure plates in the kitchen were free of debris. These failures could place residents at risk of cross-contamination and foodborne illness.

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 drugs and biologicals) to meet the needs of 1 of 8 residents (Residents #12) reviewed for pharmacy services. -The facility failed to dispose of Resident #12's Rivastigmine's patches appropriately. These failures could result in increased side effects and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #32) reviewed for significant medication errors. -MA N attempted to administer Eliquis 5 mg (a blood thinner) to Resident #32 instead of Eliquis 2.5 mg according to Physician orders. Surveyor intervened. This failure could result in increased side effects and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 6 residents (Resident #18) reviewed for call lights. -The facility failed to ensure Resident #18's call button by her bed was working. This failure could place residents at risk of injury, pain, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 8 residents (Resident #12) reviewed for pests, in that: -Resident #12 had one medium sized roach and approximately five small black ants crawling in bed with her. This failure could place residents at risk of residing in an environment with pests.

Inspectors wroteBased on observations, interviews, and record reviews, 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 (Resident #74) of 6 residents viewed for infection control. -CNA R did not wear appropriate PPE when providing care to Resident #74 during incontinence care. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building.

Inspectors wroteBased on interview and record review the facility failed to ensure residents have the right to be free from neglect for 3 of 11 residents (Resident #1, Resident # 6, and CR #7) reviewed for neglect in that: -The facility system for obtaining medical care for un-witnessed falls was not effective in protecting the health & safety of residents as follows: -The facility failed to transfer Resident #1 to the hospital immediately when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. sustaining a head injury. Resident #1 was receiving the medication Eliquis (blood thinner) and was not transferred to the hospital until 8:00 a.m. Resident #1 is scheduled for surgery on 9/14/23 due to brain bleed. -The NF delayed in calling the physician and sending Resident #6 to a higher level of care to be evaluated when Resident #6 had an unwitnessed fall with head injury on 08/19/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 11 residents (Resident #1) reviewed for quality of care in that: -The facility failed to transfer Resident #1 to the hospital in a timely manner when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. and sustained a head injury. Resident #1 was receiving Eliquis (blood thinner). Resident #1 was not transferred to the hospital until after 8:00 a.m. Resident #1 is scheduled to have surgery on 9/14/23 due to brain bleed. - The facility failed to call 911 services to transport Resident #1 to a higher level of care instead, used their non-emergency transportation to send resident to the hospital. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 2 of 11 residents (Resident #6 and CR #7) reviewed for accidents in that: -The facility failed to implement Resident #6 care plan to monitor resident to prevent fall from wheelchair developing a right frontal contusion and displaced fracture of the right frontal calvarium (section of the skull). -The facility failed to take proper precautions when CR #7 who x-ray results revealed loss of normal cervical lordosis (improper alignment of the neck) experienced an unwitnessed fall. CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 3 of 5 residents reviewed for food temperature. The facility failed to provide food that was palatable for 3 of 4 (R#2 #3,#4) residents served (Regular,) at 2 of the 3 meals observed. The facility failed to have sufficient staff to deliver meals to the resident rooms in the required time frame. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 (Resident #5) of 15 residents reviewed for resident call system. The facility failed to make sure the call light was in reach for Resident #5. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 8 percent based on 3 errors out of 35 opportunities, which involved 3 of 5 residents (Resident #12, Resident #25 and Resident #42) reviewed for medication errors. - Charge Nurse Y failed to ensure Resident #25 received her right dose of fluticasone, a nasal spray used for allergies and congestion, by allowing the resident to self- administer 2 sprays in each nostril instead of 1. - MA A failed to appropriately administer Resident #42's medication as ordered by crushing Metoprolol Succinate ER, an extended release blood pressure medication that should not be crushed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles and stored in locked compartments under proper temperature controls for 2 of 2 medication carts. (300/400 Hall Medication Aide Cart, 300 Hall Nursing Cart) - The facility failed to ensure the 300/400 Hall Medication Aide Cart did not contain medication without appropriate pharmacy labels. - The facility failed to ensure the 300 Hall Nursing Cart did not contain insulin pens with no open date This failure could place residents at risk of adverse medication reactions.

Inspectors wroteThe facility failed to implement a comprehensive person-centered care plan for 1 of 19 residents (Resident #141) reviewed for care plans, in that: - LVN F failed to ensure Resident #141's tube feeding order was followed. This failure placed all residents at risk for not having their physician orders follow and receiving inadequate care.

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 drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #79) reviewed for pharmacy services. -The facility failed to acquire medication from an appropriate source by receiving Resident #79's HIV medication from a clinic without a prescription. - The facility failed to ensure expired medication was not administered to Resident #79. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Finding Included: Record review of Resident #79's face sheet dated 03/14/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately equip all residents to call for staff assistance through a communication system for 1 of 24 residents (Resident #1) reviewed for call device. The facility failed to ensure the call device system worked in Resident #1's room. This failure could place residents at risk for delayed care or response in the event of an emergency due to resident being unable to directly contact staff in a timely manner.