Cypress Pointe Health Campus

Based on interview, record review, review of internal investigation log, and policy review, the facility failed to notify a resident's power-of-attorney (POA) following a significant medication error. This affected one (Resident #87) of four residents reviewed for notification after a change in condition. The facility census was 66.Findings include:Review of the closed medical record for Resident #87 revealed an admission date of 11/03/25 and discharged on 11/13/25. Diagnoses included fractured left femur, acute post hemorrhagic anemia, dementia, type two diabetes, hypertension, heart failure, and atherosclerotic heart disease. Review of the Incident log from 09/01/25 through 12/11/25 revealed a medication error on 11/11/25 at 6:55 A.M. involving Resident #87. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/10/25, revealed the resident was moderately cognitively impaired and dependent on staff for medication administration. Review of the blood pressure readings for Resident #87 on 11/11/25 revealed the residents blood pressure was 88/56 millimeters 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.

Based on medical record review, observation, staff interview, review of the facility policy, the facility failed to ensure proper hygiene was completed during wound care. This affected one (Resident #24) of three residents reviewed for pressure sores. The facility census was 66 residents. Findings include: Review of the medical record for Resident #24 revealed an admission date of 06/14/24 with diagnoses including type two diabetes mellitus, chronic kidney disease, and congestive heart failure. Review of the physician's orders for Resident #24 revealed an order dated 07/10/24 to cleanse the wound to the right foot/ankle with wound cleanser or normal saline, apply calcium alginate, and cover with dressing every day or as needed. Observation of wound care for Resident #24 per Licensed Practical Nurse (LPN) #20 on 07/22/24 at 3:59 P.M. revealed the nurse performed hand hygiene prior to starting the wound treatment and donned gloves. During wound care, LPN #20 removed the old dressing and cleansed the wound without changing her gloves and performing hand hygiene. LPN #20 continued to…

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 resident and staff interviews, and record review, the facility failed to ensure medications were supplied by the pharmacy to be administered per physician order. This affected one (Resident #1) of three residents reviewed for medications. The facility census was 67. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 included intervertebral disc disorder, arthritis, asthma, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of Resident #1's care plans dated 07/2023 revealed a focus for resident exhibiting a verbal difficulty with compliance of medication administration. Interventions included assessing for unmet needs, assist the resident with comprehension of policies and regulations, determine cause for behaviors, and observe for triggers to behaviors. Review of the physician orders revealed on 06/30/23, Resident #1 was ordered…

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 medical record review, staff and resident interviews, and review of facility policy, the facility failed to have care conferences for residents. The facility also failed to ensure interdisciplinary team members (IDT) were present at care conferences. This affected four (#12, #18, #20, and #30) of four reviewed for care plans. The census was 60. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 08/07/20. Diagnoses listed included hemiplegia and hemiparesis, chronic kidney disease, type 2 diabetes mellitus, aphasia, dysphagia, and major depressive disorder. Review of Minimum Data Set (MDS) assessments revealed an annual assessment was completed on 07/13/22. Further review of Resident #12's medical record revealed no evidence of a care conference being completed from 07/13/22 to 10/12/22. Review of care conference documentation dated 01/07/22 and 04/05/22 revealed the only staff member present during care conferences was the Social Service Director (SSD) #89.…

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 observations, review of the facility census, review of a list of diet orders, staff interview and policy review, the facility failed to ensure the legacy kitchen was free from expired food items and a food item was stored in a sanitary manner in the 200 unit nutritional freezer. This had the potential to affect 10 (#14, #15, #25, #33, #35, #36, #37, #38, #45, and #55) out of ten residents that resided on the Legacy unit and 13 (#1, #2, #3, #5, #6, #8, #9, #13, #16, #17, #46, #48, and #57) out of 13 residents that resided on the 200 unit. The facility census was 60. Findings include: 1. Observation of the Legacy kitchen on 10/13/22 at 7:55 A.M. revealed there were two gallons of expired whole milk that were half empty dated 10/11/22 and one full gallon of expired whole milk dated 10/12/22 in the reach in refrigerator. Interview on 10/13/22 at 7:55 A.M. with [NAME] #6 verified there were two gallons of expired whole milk that were half empty dated 10/11/22 and one full gallon of expired whole milk dated 10/12/22 in the Legacy unit kitchen refrigerator. Review of the facility…

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 record review, review of the resident fund accounts, staff interviews and policy review, the facility failed to ensure a personal funds account authorization was in place before managing a residents funds. This affected one (#36) of four fund accounts reviewed. The census was 60. Findings include: Medical record review for Resident #36 revealed an admission date of 02/07/20 and diagnosis of Alzheimer's dementia. Review of the Minimum Data Set assessment dated [DATE] revealed she had severely impaired cognition. The resident's son was her responsible party. Review of the resident fund accounts revealed Resident #36 had $1,932.09 in a fund account with no evidence of an authorization for the account. There was evidence of social security deposits into the account each month and withdraws from the resident's account. Interview on 10/12/22 at 11:30 A.M. with the Business Office Manager (BOM) #1 verified there was no authorization for the fund account for Resident #36 with a current balance of $1,932.09…

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 medical record review, staff interview and policy review, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two (#24 and #49) of five residents reviewed for to unnecessary medications. The facility census was 60. Findings include: 1. Review of the Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, difficulty in walking, muscle weakness, cognitive communication deficit, dysphagia, type two diabetes mellitus with diabetic neuropathy, retention of urine, hyperlipidemia, major depressive disorder, unspecified cataract, heart failure, legal blindness, hallucinations, and unspecified dementia with behavioral disturbance. Review of Resident #24's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #24 required extensive assistance with bed mobility, transfers, dressing, eating,…

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 medical record review, observation, staff interview, review of facility policy, and review of manufacturer guidelines, the facility failed to ensure staff primed an insulin pen devices before administration resulting in a significant medication error. This affected one (#24) of four residents observed for medication administration. The census was 60. Findings include: Review of Resident #24's medical record revealed an admission date of 05/21/18. Diagnoses listed included muscle weakness, dysphagia, type two diabetes mellitus, hypertension, legal blindness, and major depressive disorder. Resident #24 was assessed as being severely cognitively impaired and requiring extensive assistance in a significant change Minimum Data Set (MDS) assessment dated [DATE]. Review of physician orders revealed an order dated 09/29/22 for a Basaglar Kwikpen (insulin pen) 100 units per milliliter (units/ml), inject 15 units subcutaneously (SQ) twice a day. An order dated 08/21/21 was for Novolog Flexpen (insulin pen) 100…

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 medical record review, observations and staff interview, the facility failed to ensure that all wound interventions were available and implemented upon admission. This affected one (#218) out of three reviewed for skin breakdown. The facility census was 68. Findings include: Medical record review for Resident #218 revealed an admission date on 10/09/19 with diagnosis that include cellulitis of left lower limb, non pressure chronic ulcer of other part of left foot, diabetes mellitus, staphylococcus, sepsis, blood clot, abnormal heart beat, diabetic neuropathy, gangrene gas, obesity, high blood pressure, anticoagulant use, insulin dependent and acquired absence of left great toe. Review of Resident #218's hospital discharge orders dated 10/09/19 revealed an order for a waffle boots over dressing on left foot, elevate and off load. Further review of Resident #218's admitting physicians orders revealed the order for the waffle boot was not on the document. Review of Minimum Data Set (MDS) assessment dated…

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.