Cypress Pointe Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Cypress Pointe Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 23, 2026

  Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 45 residents (Resident #95), in the survey sample which constituted harm.The findings included: The facility staff failed to provide adequate supervision to ensure Resident #95 was safe from falling while providing activities of daily living (ADL) care which constituted harm.Resident #95 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #95 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included unspecified dementia without behavioral disturbance, major depressive disorder, and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF887Feb 23, 2026

  Based on information obtained during the Infection Control task, the facility staff lacked documentation of all staff members' COVID-19 information. The findings included: On 2/21/26 at approximately 10:05 AM, the Infection Control information for the facility's staff was requested. The Director of Nursing (DON) stated at 4:38 PM that she was unable to locate COVID-19 information for all staff. There was no documentation that any staff had been provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine, or that staff were offered the COVID-19 vaccine or information on obtaining it.On 2/22/26 at 4:40 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. […]

• No harm, potential for more than minimal, widespreadF880Aug 4, 2022

  Based on staff interview and facility document review, the facility staff failed to maintain a complete infection control surveillance program. The facility staff failed to maintain a complete surveillance system with enough data collection to properly track infections. The findings include: A review of the facility infection control surveillance program for January 2022 through June 2022 revealed the following: -Folders for January 2022 through April 2022 only contained a list of residents that were prescribed an antibiotic and information regarding the antibiotic prescription, lab tests results related to various infections for various residents and a color coded facility floor plan that tracked infections by categories of urinary infections, respiratory infections, gastrointestinal… […]

• No harm, potential for more than minimal, widespreadF886Aug 4, 2022

  Based on staff interview and facility document review, the facility staff failed to conduct COVID-19 testing in a manner consistent with professional standards of practice. The facility staff failed to conduct complete COVID-19 testing during a facility outbreak that began on 6/10/22. The findings include: A review of facility documentation revealed the facility began COVID-19 outbreak status on 6/10/22 because a resident tested positive. A review of facility testing documentation revealed the following: On 6/10/22, all residents were tested and eight residents were positive for COVID-19. No staff were tested . On 6/13/22, only residents who were symptomatic or exposed were tested . Ten residents were positive. […]

• No harm, potential for more than minimal, patternF609Feb 23, 2026

  Based on staff interviews, facility document review, and clinical record review, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for two (2) of 45 residents in the survey sample, Resident #10 and Resident #42. The findings included: 1.The facility staff failed to report an allegation of abuse to the appropriate state agency. Resident #10 was originally admitted to the facility 11/27/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Pain and Insomnia, unspecified. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/25/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. […]