Lodge at Cypress Cove, The

In the surveyor’s words

From the most serious findings on record at Lodge at Cypress Cove, The, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF640Jan 18, 2024

  Based on record review and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments in a timely manner for 16 residents (Residents #1, #2, #3. #6, #12, #17, #19, #20, #26, #29, #35, #37, #39, #40, #43 and #44) of 16 residents reviewed. The finding included: Record review for Resident #1's MDS assessments revealed the Quarterly MDS dated [DATE] was transmitted 1/16/24, 32 days after completion. The Annual MDS dated [DATE] was transmitted on 10/10/23, 26 days after completion. Record review for Resident #2's MDS assessments revealed the Quarterly MDS dated [DATE] was transmitted on 1/17/24, 49 days after completion. Record review for Resident #3's MDS assessments revealed an Admission assessment dated [DATE] was transmitted on 10/10/23, 28 days late. […]

• No harm, potential for more than minimal, patternF689Jan 18, 2024

  Based on observation, record review, review of facility's policies and procedures, residents, resident's representatives and staff interviews, the facility failed to ensure adequate supervision to ensure safety and prevent falls for 3 (Residents #42, #8 and #206) of 3 residents reviewed for falls. The findings included: The facility policy Fall Review Program (revised 7/23) documented the facility strives to identify those residents at risk for falls, to provide a system of evaluation, reevaluation, and implementation of measures to reduce the potential for falls/additional falls. All residents will be reviewed for fall risk on admission/readmission and after an actual fall, and quarterly thereafter. […]

• No harm, potential for more than minimal, isolatedF656Jan 18, 2024

  Based on observation, record review, and interview, the facility failed to develop and implement an individualized care plan to prevent decline in range of motion for 1 (Resident #29) of 2 residents reviewed with limited range of motion. The findings included: The facility policy, Plan of Care revised July 2023 noted, It is the policy of Cypress Cove to develop and implement a comprehensive person-centered care plan for each resident . that are identified in the resident's comprehensive assessment . Review of the clinical record for Resident #29 revealed an admitted [DATE] with diagnoses including Dementia and muscle weakness. […]

• No harm, potential for more than minimal, isolatedF688Jan 18, 2024

  Based on observation, record review, and staff interview, the facility failed to provide care and services to prevent the decline in range of motion for 1 (Resident #29) of 2 sampled residents with functional limitation in range of motion. The findings included: A review of the Restorative Nursing Programs health care policy (R-12) revised June 2018 provided by the facility stated, Cypress Cove strives to provide maintenance and restorative services designed to maintain or improve a resident's ability to the highest practicable level. The procedure documented, Nursing personnel are training on basic, maintenance or restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. […]

• No harm, potential for more than minimal, isolatedF761Jan 18, 2024

  Based on observation, review of facility policy and staff interviews, the facility failed to ensure expired medications were not retained longer than the expiration date in 1 of 2 medication storage rooms observed and 1) medication cart of 3 medication carts observed. This has the potential for expired medications to be administered to residents. The findings included: The facility policy and procedure Medication Storage (revised 8/23) documented All medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdates, defective or deteriorated medications with worn, illegible or missing labels. […]