Cypress Garden Center for Nursing and Rehabilitati

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the abbreviated survey (NY00375573), the facility failed to ensure a resident was protected from abuse of any kind by anyone. This was evident for one (1) out of five (5) residents (Resident #1). Specifically, on 3/19/2025 Licensed Practical Nurse (#1) pulled Resident #1 on to and off the elevator. This was witnessed by Certified Nursing Assistants # 1, #2, Security Guard #1, and Registered Nurse Supervisor #1. The findings are: The facility's Policy and Procedure titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's Property, dated 03/20/2025, documented the purpose of the policy is to ensure a resident was protected from abuse of any kind by anyone. The policy stated abuse does not have to be intentional and can still be considered abuse if the potential for harm is present. The policy defines willful as acting deliberately, not that the individual must have intended to inflict injury or harm. The facility's Summary of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews during the re-certification survey, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of resident equipment layered with dirt and dust, room furniture heavily worn and torn seat cushion, room walls with streaks and stains, ice machines covered with rust stains, floor corners embedded with grime and dirt, base of dining room tables heavily worn and rust stains, nurse station area floor and walls layered with dirt and dust and entangled loose wires, torn or stained privacy curtains. This was evident for 3 of 7 units. (Units: 3, 4 and 6). The findings are: The facility policy titled, Homelike Environment, dated 06/18/24 documented, It is the policy of the facility to ensure that all residents live in an environment that is clean and neat with appropriate furnishings and in good repair. Upon the initial entrance to the facility on [DATE] at approximately 9:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, during the re-certification survey, the facility did not ensure the resident and staff physical environment was kept safe and clean. Specifically, 1.) Nurse Station 2.) Lobby Restrooms and Floor Tiles 3.) Staff Bathroom. This was evident in the Lobby area including 3 of 7 units. ( Units 3, 4 and 6). The findings are: The facility policy and procedure titled, Homelike Environment, dated 06/18/24 documented, The facility respectfully acknowledges that all residents are entitled to living in an environment that is like a homelike setting. Upon the initial entrance to the facility on [DATE] at approximately 9:00 AM and subsequent observations during the recertification survey the following environmental issues were observed: A) Lobby Area: 1. Broken floor tiles along the corridor. B) Lobby Rest Rooms: 1. Rest Room located across the out of order sign noted with unidentifiable offensive odor emitting from the bathroom. 2. Sink not firmly affixed to the wall. 3. Toilet seat loose.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during the Recertification survey from 9/16/2024 to 9/23/2024, the facility did not ensure that a Comprehensive Care Plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to Communication: vision/hearing, was not revised based on a resident's need for a hearing aid. This was evident for 1 (Resident #207) of 3 residents reviewed for Communication' vision/hearing, out of 38 total sampled residents. The findings are: The facility's policy titled Comprehensive Care Plan, last reviewed 2/12/24, documented that each resident's comprehensive care plan shall be reviewed and updated by the interdisciplinary team as per the Minimum Data Set 3.0 schedule, quarterly, annually, significant change in condition, and if the resident's condition warrants it. Resident admitted to the facility with diagnoses that include Depression and Anxiety Disorder. On 09/16/24 at 10:58 AM, Resident #207 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. Specifically, Resident #160 was observed on several occasions the hearing aid in place. This was evident for 1 (Resident #160 ) of 2 residents reviewed for Communication and Hearing Care Area. The finding is: The facility policy and procedure dated, 01/05/24 titled, Hearing Impaired and Care of, documented, 'It is the policy of the facility staff will assist hearing impaired residents maintain effective communication with clinicians, caregivers and other residents. Resident #160 has diagnoses including but not limited to Hearing Loss, Hypertension and Cerebral Vascular Accident. The Quarterly Minimum Data 3.0 Assessment Reference Date of 08/08/24 documented the resident was admitted on [DATE], with minimal hearing difficulty, hearing aid appliance in use, clear speech, usually understood, usually…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review conducted during the recertification survey from 09/16/2024 to 09/23/2024, the facility did not ensure a resident right to self-determination was honored. This was evident for 1 of 3 Residents (Resident #69) investigated for Abuse out of a total sample of 35 Residents. Specifically, Certified Nursing Assistant repeatedly attempted to render care to Resident #69 despite Resident #69 refusing care. The findings are: The facility's policy titled, Resident Rights Policy and Procedures last reviewed 6/11/2024 documented this facility is committed to assuring the rights and protection of its residents as stipulated under Federal and State Laws. Resident's rights include but are not limited to the following: Treated with respect, dignity and self-determination with care. Quarterly Minimum Data Set, dated [DATE] documents that Resident #69 is cognitively intact with a BIMS score of 15. Resident is dependent with all activities of daily living care and transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the Recertification Survey conducted from 6/27/22 to 7/5/22, the facility did not ensure a resident was provided with the necessary services to carry out activities of daily living (ADL). This was evident for 1 (Resident #143) of 2 residents reviewed for ADLs. Specifically, there were multiple observations of Resident #143 with long uncut toenails. The findings are: The facility policy titled ADLs last reviewed 2/28/2022 documented residents' needs are met in a timely manner and the Certified Nursing Assistant (CNA) provides care and assistance in accordance with nursing instructions. Resident # 143 had diagnoses of acute osteomyelitis and neuralgia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 143 had mild cognitive impairment, did not reject care, and required extensive assistance of 1 person to perform personal hygiene. On 06/27/22 at 11:25 AM, Resident # 143 was observed with toenails on both feet extending a half inch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interviews during recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, potentially hazardous cold foods (sandwiches) were not maintained at the proper temperature (at or below 41 degrees Fahrenheit), and equipment used to slice meat for sandwiches was not properly cleaned after use. This was evident during the Kitchen Observation facility task. The findings are: 1) The policy and procedure titled Sandwich preparation last reviewed 6/19/18, documented: All items for sandwiches, for example Egg salad/Tuna salad and any deli meats, are held under refrigeration at 40 degrees or less prior to assembly. Sandwiches will be assembled on an appropriate cutting board, and upon completion, each sandwich is wrapped and dated. They are then placed back into the refrigerator. Sandwiches are assembled for same day use and discarded at end of the day. The policy and procedure titled Hot and Cold food holding effective 4/20/16 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview during the recertification survey, the facility did not ensure that a homelike environment was provided. Specifically, resident rooms were observed with bare white walls and lacking decor, creating a colorless, dull environment. This was observed for 3 residents (Resident #s 110, 218, and 204) on one (1) of six (6) resident units (Unit 3). The findings are: A review of the facility's policy and procedure for, 'Homelike Environment, documented: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These include: inviting color and decor. 1.) Resident #110 was admitted on [DATE]. The resident was alert and oriented to person, place and time, with moments of confusion. During the initial unit tour, on 09/17/19 at 9:10 AM, the resident's room was observed. The room walls were painted off white and the wall space facing the resident was bare. An Activities, calendar was posted on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the re-certification survey, the facility did not ensure that each resident was treated with dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, a resident was observed wearing oversized soiled and tattered sneakers with no socks. This was evident for one (1) of one (1) resident reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. Resident #1 was admitted on [DATE] with diagnoses which included Alzheimer's Dementia. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 09/10/19, documented that the resident had clear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure that medically related social services to attain and maintain the highest practicable physical, mental and psychological well - being of each resident were provided. Specifically, a resident observed wearing oversized, soiled, and tattered sneakers without socks was not assisted with obtaining new footwear and socks. This was evident for one (1) of one (1) residents reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. Resident #1 was admitted on [DATE] with diagnoses which included Alzheimer's Dementia. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 09/10/19, documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during the Re-Certification Survey, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition. Specifically, a resident with wandering and elopement risk behaviors was prescribed psychotropic medications without an appropriate diagnosis. In addition, the facility did not attempt any non-pharmacological interventions targeted to address the psychosocial stressors of loss of home and family moving away that contributed to the behavior prior to starting the medication. This was evident for one (1) of five (5) residents investigated for Unnecessary Medication (Resident # 51). The finding is: The policy for, Psychotropic Drugs & GDR (Gradual Dose Reduction), dated 03/20/19, documented the following: That residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interviews during the recertification survey, the facility did not ensure the infection prevention and control program desgned to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained. Specifically, the consultant eye doctor did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam. This was evident for 1 random observation (Resident #199) on 1 out of 6 resident units (2nd floor). The finding is: The facility policy titled Handwashing, reviewed and revised on 7/2017, documented that handwashing should be done before and after resident contact. Proper handwashing technique includes the following steps: Wet hands with running water. Apply soap and throughtly distributed over hands. Vigorously rub hands together for 20 seconds covering all surfaces of the hands and fingers. On 09/19/19 at 10:09 AM, the Eye Doctor was observed preparing to see residents on the 2nd floor. The Eye Doctor borrowed an overbed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.