Cypress Pointe Health & Wellness

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure that assessments accurately reflected residents' status for 2 of 22 residents (Resident #2 and Resident #12) reviewed for accuracy of assessments. - The facility failed to ensure Section E of Resident #12's admission MDS completed on 02/27/26 accurately reflected her behaviors and rejection of care. - The facility failed to ensure Section I of Resident #2's Quarterly MDS completed on 01/13/26, Quarterly MDS completed on 10/13/2025, Annual MDS completed on 08/20/2025 accurately reflected her active diagnoses. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included:Resident #2 Record review of Resident #2's Face sheet dated 03/06/2026 revealed a 74- year- old female who admitted to the facility on [DATE] with diagnoses which included: vascular dementia(a brain condition caused by reduced blood flow, often from brain attack or damaged blood vessels,…

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 Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 3 of residents (Resident #7, Resident #111, and Resident #121) reviewed for respiratory and tracheostomy care. - ADON C failed to assess Resident #7's respiratory status when he was observed with his oxygen mask off his tracheostomy tube.- RN B failed to assess Resident #7's respiratory status before and after performing tracheostomy ( a surgically created opening into the windpipe allowing breathing, bypassing upper airway obstructions) care on 03/04/26.- The facility failed to ensure Resident #7 received O2 as ordered when he was administered 4L instead of 6L as…

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, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 5 of 5 medical supplies, (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals,) reviewed for medication storage and labeling.The facility failed to ensure the medication room was free from expired medical supplies on [DATE].This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition (change of a substance into something else, often making it weaker, useless, or harmful), and could cause infections due to compromised sterile equipment.Findings included: During an observation of 300 hall's medication cart and interview on [DATE] at 10:28 a.m., revealed staff stored expired eSwab tubes (a system of a liquid-based, FDA-cleared device for collecting and transporting wound cultures) count 2, both expired on [DATE]. LVN J…

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, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. -The facility failed to ensure food items were labeled and dated. This failure could place residents at risk of foodborne illness and disease.Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. - The facility failed to ensure food items were labeled and dated. This failure could place residents at risk of foodborne illness and disease. Findings include: Observation of the facility's kitchen on 3/4/2026 at 8:18 a.m. revealed the following: An open container of Homestyle Mayonnaise, 1 gallon, in the refrigerator were not dated. In an interview on 3/6/2026 at 10:18 a.m. with the Kitchen Manager, she stated everything in the refrigerator was labeled except the mayonnaise. She…

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 Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1of 3 (Resident #70) residents reviewed for parenteral fluids. - The facility failed to ensure the dressing of Resident #70's IV line was changed weekly as ordered. This failure could place residents at risk for unwanted infections and further decrease in quality of life. Findings included: Record review of Resident #70's Face Sheet dated 03/05/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: skin infection (cellulitis) of the left upper limb, type 2 diabetes, anxiety and obesity (excessive fat accumulation). Record review of Resident #70's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS…

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, interview and record review the facility failed to ensure the medication error rate was not 5% or greater. The facility had a medication error rate of 6.0%, based on two errors out of 29 opportunities, which involved 2 of 4 residents (Residents #3 and #64) and 2 of 2 (RN B and MA C) staff observed during medication administration reviewed for medication errors. -The facility's staff failed to administer scheduled medications to Residents #3 and #64.-This failure could place residents at risk of receiving less than optimal results from their medication regimen.Findings included:. Record review of Resident #64's Physician Orders, dated 03/05/2026, revealed active orders of the following medications:- Amlodipine oral (by mouth) tablet 10 mg. Give 1 tablet by mouth one time a day for High blood pressure.- Aspirin low dose oral tablet 81 mg. Give 1 tablet by mouth one time a day related to paroxysmal atrial fibrillation (irregular heart rhythm).- Buspirone tablet 5 mg. Give 2 tablet by mouth three times a day for anxiety (the body's response to stress,…

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 Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 22 Residents (Resident #65) reviewed for food prepared in a form designed to meet individual needs. The facility failed to ensure Resident #65's dietary orders and preference of a mechanical soft diet when were followed when the resident was served dry lightly toasted toast for breakfast and boiled potatoes with the skin for lunch on 03/05/2026. This failure could place residents at risk of difficulty chewing, choking and weight loss. Findings include: Record review of Resident #65's face sheet, dated 03/05/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #65 had diagnoses which included: paralysis and weakness on the right dominant side following a stoke ( brain damage caused by a blockage in a blood vessel do to lack 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 Number of residents sampled: Number of residents cited: Based on observation, interview and record review 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 diseases and infections for 2 of 5 residents (Residents #7 and Resident #57) reviewed for infection control practices.1. ADON C failed to follow infection control practices when she cleaned Resident #7's trach with a towel that sat on the resident's chest on 03/04/26.2. RN B failed to follow infection control practices and did not use aseptic (sterile) technique when she suctioned Resident #7's Trach on 03/04/26 and 03/05/26.3. The facility failed to ensure a used single use push button lancet (a device with a hiding needle used to prick the skin for blood samples) was not left on Resident 57's nightstand on 03/04/2026. These failures could place residents at risk of bloodborne pathogens,…

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 reviews and interviews, the facility failed to be 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 to each resident's bedside;abd /toilet and bathing facilities for 1 of 5 residents (Resident #1) reviewed for call lights.The facility failed to ensure Resident #1's call light was within reach on 02/06/2026, while he was lying bed.This failure could place residents at risk of not receiving immediate assistance when needed. Findings included: Record review of Resident #1's Face Sheet revealed, a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included muscle wasting, abnormality of gait and mobility, difficulty in walking, and lack of coordination.Record review of Resident #1's most recent Quarterly MDS (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status, used in nursing…

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, interview and record review the facility failed to ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 20 residents (Resident #85) reviewed for respiratory care. The facility failed to set the flow rate at 2 liters of oxygen per the order for Resident #85. This deficient practice could place residents at risk of incorrect or inadequate respiratory support and could result in a decline in health. Findings include: Record review of Resident #85's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included hypertensive heart disease with heart failure (left changes in the heart as a result of chronic elevated blood pressure), paroxysmal atrial fibrillation (intermittent rapid, erratic heart rate that stops on its own), Chronic systolic…

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, interview and record review the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 23 residents (Residents #42) reviewed for pharmacy services. The facility failed to ensure Midodrine (a low blood pressure medication) given to elevate hypotension (low blood pressure) was administered to Resident #42 as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings include: Record review of Resident #42's admission face sheet dated 11/14/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #42 had diagnoses which included: rheumatoid lung disease with rheumatoid arthritis on multiple sites (a chronic inflammatory disorder affecting many…

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.