Cypress Grove Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Oct 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure full time qualified staff was hired, a certified dietary manager was not employed at the facility since June, 2021, and failed to have a full time dietician at the facility since June 2021 to cover the daily operations of the dietary department. (Kitchen) Findings include: On 10/25/21 at 8:40 a.m., Cook 1 indicated the facility had not had a dietary manager for several months. She indicated she had been ordering the food for the facility. On 10/25/21 at 1:30 p.m., the Administrator indicated the facility had been without a dietary manager since the summer and did not have a full-time dietary manager. The facility had been searching for a new dietary manager but had not really had any applicants. […]

• No harm, potential for more than minimal, widespreadF801Sep 10, 2021

  Based on interview and record review, the facility failed to ensure a full time qualified dietitian or certified dietary manager was employed at the facility since May 2021. (Kitchen) Findings include: On 9/9/21 at 9:10 A.M., during an interview with Dietary 1, she indicated the facility had not had a dietary manager for several months. On 9/10/21 at 9:15 A.M., during an interview with the Administrator, he indicated the facility had been without a dietary manager since May 2021. The facility had posted the position for 2 months, and then added a signing bonus. They have had applicants, but no one had been certified. The corporation was basically handling trying to obtain someone. […]

• No harm, potential for more than minimal, patternF677May 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for assistance with daily living (ADL) tasks were provided showers or baths for 4 of 6 residents reviewed for ADL care. (Resident 78, Resident 25, Resident 69, and Resident 12) Findings include: 1. On 5/28/25 at 10:30 A.M., Resident 78's clinical record was reviewed. Resident 78 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 Diabetes Mellitus. The most recent Admission MDS Assessment, dated 3/31/25, indicated Resident 78 was dependent on staff (staff do all of the work) for bathing and transfers. A shower schedule, provided by the Director of Nursing on 5/30/25 at 9:14 A.M., indicated Resident 78's scheduled shower days were Tuesday and Saturday. […]

• No harm, potential for more than minimal, patternF677May 17, 2024

  Based on interview, observation, and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADLs) received showers for 6 of 7 residents reviewed for ADLs. (Resident 40, Resident 46, Resident 20, Resident 12, Resident 19, Resident 75) Findings include: 1. On 5/13/24 at 2:04 P.M., Resident 40 indicated he only got a shower once a week, but he would prefer to take a shower three times a week. At that time, Resident 40 was observed to have dandruff on his shirt. On 5/16/24 at 9:39 A.M., Resident 40's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF690Nov 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure routine catheter care was provided and infection control measures were maintained to prevent the development of urinary tract infections for 3 of 4 residents reviewed for catheter care. Routine catheter care and monthly catheter changes were not provided as ordered by a physician and catheter tubing was observed on the floor during 2 of 2 days of the survey. (Resident C, Resident D, Resident F, Resident G) Findings include: 1. During record review on 11/28/23 at 11:20 A.M., Resident C's diagnoses included, but were not limited to dementia, urinary tract infection, severe sepsis, hydroureter, type II diabetes, obstructive and reflux uropathy, and chronic kidney disease. […]