Cypress Grove Post Acute

In the surveyor’s words

From the most serious findings on record at Cypress Grove Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 14, 2022

  Based on policy review, medical record review, observation, and interview, the facility failed to provide a safe environment and ensure supervision to prevent neglect for 1 of 3 sampled residents (Resident #36) reviewed for elopement risk. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy when Resident #36, a vulnerable resident with severe cognitive impairment was found 0.9 miles from the facility on a warm summer day. The facility was unaware of the resident's location for approximately 30-45 minutes. […]

• Immediate jeopardy, isolatedF689Jul 14, 2022

  Based on policy review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for 1 of 3 sampled residents (Resident #36) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy when Resident #36, a vulnerable cognitively impaired resident, exited the facility unsupervised through an unlocked door. Resident #36 was found by a facility staff member driving on her lunch break approximately 0.9 miles from the facility, approximately 30-45 minutes later. […]

• Actual harm, isolatedF686Sep 25, 2024

  Based on the National Pressure Injury Advisory Panel 2019 Guidelines, policy review, medical record review, observation, and interview, the facility failed to provide care and services to appropriately identify pressure ulcers/pressure injuries (PU/PIs), to provide services to promote healing, and to promptly notify the physician or practitioner for changes in the right foot PU/PI wound status to reduce the risk for infection for 1 of 4 (Resident #9) sampled residents reviewed for PU/PIs. […]

• No harm, potential for more than minimal, patternF880Jul 14, 2022

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were followed when 1 of 1 nurses (Licensed Practical Nurse (LPN) #7) failed to perform proper hand hygiene during wound care for 2 of 2 sampled residents (Resident #32 and #43) reviewed during wound care. The findings include: Review of the facility's policy titled, Hand Hygiene, dated 3/2022, revealed .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .The use of gloves does not replace hand hygiene .Perform hand hygiene after removing gloves .Before and after handling clean or soiled dressings .Before performing resident care… […]

• No harm, potential for more than minimal, isolatedF695Jul 15, 2026

  Based on facility policy review, the facility Treat in Place Protocol review, medical record review, observation, and interview, the facility failed to follow physician orders for the use of oxygen for 1 of 2 (Resident #5) sampled residents reviewed for oxygen. The findings include: 1. Review of the facility policy titled, Oxygen Administration, dated 10/2010, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration.Verify that there is a physician's order for this procedure. […]