Deficiency Records for Cypress Pointe Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Cypress Pointe Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-22 | 2022-09-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-22 | 2022-09-28 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-04 | 2022-09-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-04 | 2022-09-02 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-04 | 2022-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-04 | 2022-09-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-04 | 2022-09-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-04 | 2022-09-02 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-08-04 | 2022-09-02 | N |
| Post nurse staffing information every day. | Health | 2022-08-04 | 2022-09-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-04 | 2022-09-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-04 | 2022-09-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-09-02 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-04 | 2022-09-02 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-08-04 | 2022-09-02 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-08-04 | 2022-09-02 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-08-04 | 2022-09-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-04 | 2022-09-02 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-08-04 | 2022-09-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-04 | 2022-09-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-04 | 2022-09-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-04 | 2022-09-02 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-04 | 2022-09-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-04 | 2022-09-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-09-02 | Y |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2022-08-04 | 2022-09-02 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2022-08-04 | 2022-09-02 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-04 | 2022-09-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-04 | 2022-04-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-20 | 2021-06-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-20 | 2021-06-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-20 | 2021-06-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-20 | 2021-06-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-05-20 | 2021-06-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-20 | 2021-06-30 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-20 | 2021-06-30 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-05-20 | 2021-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-20 | 2021-06-30 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-11-22 | 2020-01-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-22 | 2020-01-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-22 | 2020-01-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-22 | 2020-01-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-22 | 2020-01-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-22 | 2020-01-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-22 | 2020-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-22 | 2020-01-03 | N |
| Dispose of garbage and refuse properly. | Health | 2019-11-22 | 2020-01-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-22 | 2020-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-22 | 2020-01-03 | N |
| Develop a communication plan. | Fire Safety | 2019-11-22 | 2020-01-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-07-17 | 2018-08-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-04-12 | 2018-05-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-12 | 2018-05-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-12 | 2018-05-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-04-12 | 2018-05-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-12 | 2018-05-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-12 | 2018-05-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-12 | 2018-05-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-12 | 2018-05-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-12 | 2018-05-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-12 | 2018-05-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-04-12 | 2018-05-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-12 | 2018-05-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-04-12 | 2018-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-12 | 2018-05-25 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2018-04-12 | 2018-05-25 | N |
