Cypress Creek Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cypress Creek Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Mar 7, 2024

  Based on interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for six of 9 residents (Resident #31, #66, #90, #37, #72 and #11) reviewed for pressure sores. -The facility failed to ensure Resident #31 received wound care treatment for 38 days, did not evaluate, and obtain orders for wound care upon admission when the resident was noted to have an open wound to the buttocks. […]

• Immediate jeopardy, patternF600Jul 11, 2021

  Based on interview and record review the facility failed to ensure residents were free from abuse and neglect for 5 (Residents #1, CR#2, Resident#3, CR#4, Resident #5) of 12 residents reviewed for abuse and neglect as evidence by: Resident #1 was found sexually abusing CR#2 in her bedroom. CNA B left CR#2 alone with Resident #1 alone while he was sexually abusing CR#2. Resident #1 was found in Resident #3's bedroom after an incident of sexual abuse with CR#2. Resident #3's covers was pulled back and one side of her brief was unsnapped. LVN A failed to document an assessment after the incident between Resident #1, CR#2 and Resident #3. Resident #1 was overheard asking CR#4 to touch him on his private area. […]

• Immediate jeopardy, patternF689Jul 11, 2021

  Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent sexual inappropriate incidents for 5 (Resident #1, CR#2, Resident #3, CR#4, Resident #5) of 12 residents reviewed for sexual inappropriate behavior as evidence by: Resident #1 was found sexually abusing CR#2 in her bedroom. Resident #1 was found in Resident #3's bedroom after an incident of sexual abuse with CR#2, he had pulled her covers back and one side of her brief was unsnapped. Resident #1 was overheard asking CR#4 to touch him on his private area. Resident #1 was found touching Resident #5's breast in the hallway. An Immediate Jeopardy was identified on 07/07/21 at 12:48 PM. […]

• Immediate jeopardy, isolatedF600May 29, 2025

  Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse. CNA A was physically abusive to Resident #1 on 1/28/2025 when he slapped her on the left cheek with an open hand and pointed at her twice aggressively. The noncompliance was identified as past noncompliance (PNC). The IJ (immediate jeopardy) began on 1/28/2025 and ended on 4/22/2025. The facility corrected the noncompliance before the survey began. Resident #2 was physically abusive to Resident #1 on 4/21/2025 when she punched her in the arm with a closed fist three times. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 4/21/25 and ended on 4/22/2025. […]

• Actual harm, isolatedF684Oct 13, 2022

  Based on interviews, record reviews, and observations, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two of three residents (Resident #9 and Resident #8) reviewed for quality of care. The facility failed to properly identify change in condition for Resident # 9 and Resident #8 who were totally dependent on the staff and prevent facility acquired skin wound. Resident #9 developed a wound on the sacrum while Resident # 8 wound on right buttocks due to moisture associated skin damage. […]