Cypress Valley Center for Nursing and Rehabilitati

In the surveyor’s words

From the most serious findings on record at Cypress Valley Center for Nursing and Rehabilitati, in the surveyor’s own words.

• Actual harm, isolatedF550Sep 7, 2023

  Based on record review and resident, family, staff, and dialysis staff interviews, the facility failed to maintain a resident's dignity by failing to pick up Resident #3 from a dialysis appointment which resulted in the resident feeling terribly upset and angry for 1 of 1 sampled resident reviewed for dialysis (Resident # 3). The findings included: Resident #3 was admitted to the facility on [DATE], with diagnoses of congestive heart failure and end stage renal disease. The admission Minimum Data Set(MDS) dated [DATE], coded Resident #3's cognition was intact and received dialysis three times a week. Review of the dialysis appointment book revealed, Resident #3 did not go to dialysis on 8/7/23 and 8/9/23 and rescheduled on 8/11/23. […]

• Actual harm, isolatedF697May 25, 2023

  Based on record review and staff, resident, and Nurse Practitioner interviews the facility failed to administer opiod pain medication per physician orders for 2 of 2 residents reviewed for pain (Resident #2 and #3). Resident #3 missed 8 consecutive doses of his routine pain medication over a 2 day period and experienced increased arthritic pain of 6 on a pain scale of 1 to 10 (10 being the worst pain) and Resident #2 reported severe pain which she rated a pain scale of 7 related to bilateral (both hips) hip fractures when staff failed to administer her as needed pain medication per orders. Findings included. 1. Resident #3 was admitted to the facility on [DATE] with the diagnosis of chronic pain syndrome. […]

• Actual harm, isolatedF755May 25, 2023

  Based on observations, record review, and staff, resident, Pharmacist, and Nurse Practitioner interviews the facility failed to acquire routine and as needed (PRN) pain medications for administration resulting in the failure to administer medications as ordered and failed follow established procedures for retrieving and administering available narcotic pain medication for 2 of 2 (Resident #2 and Resident #3) reviewed for medication administration. This resulted in Resident #2 missing requested PRN pain medication for complaints of pain rated at a 7 on a pain scale of 1 to 10 (10 being the worst pain) related to bilateral (both hips) hip fractures and Resident #3 missing 8 consecutive doses of his pain medication resulting in pain which he rated a pain scale of 6 related to increased… […]

• Actual harm, isolatedF550Apr 20, 2023

  Based on staff and resident interviews, observations, and, record review, the facility failed to provide a dependent resident incontinence care after a bowel movement which caused the resident to feel embarrassed and angry (Resident #30), failed to provide a dependent resident incontinence care at breakfast time with urine soaked through to the mattress which caused the resident to feel horrible and cry (Resident #41), and failed to provide a dependent resident incontinence care when requested which made the resident feel horrible and neglected while waiting for care (Resident #245) for 3 of 5 residents reviewed for dignity. Findings included: 1. Resident #30 was admitted to the facility on [DATE] with the diagnoses of convulsions and chronic pain syndrome. […]

• No harm, potential for more than minimal, widespreadF727Jun 5, 2025

  Based on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 3 of 92 days reviewed for staffing (11/10/24,11/30/24, and 12/01/24). Findings included: A review of the PBJ (Payroll Based Journal) staffing data report for quarter 1, 2025 (October 1 - December 31, 2024) indicated the facility did not have RN Coverage on 11/10/24, 11/30/24, and 12/01/24. Review of the daily assignment sheets for the non-covered dates revealed the RN who was originally scheduled to work 7:00 AM - 7:00 PM on the dates of 11/10/24, 11/30/24, 12/01/24, and 12/27/24 had called out. The facility had not replaced the RN who called out. An interview was conducted with the Director of Nursing (DON) and the Administrator on 06/05/25 at 9:06 AM. […]