Park Manor of Cypress Station

In the surveyor’s words

From the most serious findings on record at Park Manor of Cypress Station, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 13, 2025

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision for 3 of 4 residents (CR #1, Resident#2, and Resident #3) reviewed for accidents and supervision. -CR #1 walked out of the facility unattended with a wander guard (device designed to prevent wandering in elderly) and was missing for approximately 1 hour and 9 minutes on 07/20/2024 and was located nearby an apartment complex. -The facility failed to ensure that Resident#2 had orders in place to monitor placement and functioning of a wanderguard from 07/23/2023-06/10/2025. -The facility failed to ensure that Resident#3 had orders in place to monitor placement and functioning of a wanderguard from 03/24/2025-06/10/2025. An Immediate Jeopardy (IJ) was identified on 06/11/2025. […]

• Immediate jeopardy, patternF600Sep 25, 2023

  Based on interview and record review the facility failed to ensure residents have the right to be free from neglect for 3 of 11 residents (Resident #1, Resident # 6, and CR #7) reviewed for neglect in that: -The facility system for obtaining medical care for un-witnessed falls was not effective in protecting the health & safety of residents as follows: -The facility failed to transfer Resident #1 to the hospital immediately when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. sustaining a head injury. Resident #1 was receiving the medication Eliquis (blood thinner) and was not transferred to the hospital until 8:00 a.m. […]

• Immediate jeopardy, patternF684Sep 25, 2023

  Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 11 residents (Resident #1) reviewed for quality of care in that: -The facility failed to transfer Resident #1 to the hospital in a timely manner when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. and sustained a head injury. Resident #1 was receiving Eliquis (blood thinner). Resident #1 was not transferred to the hospital until after 8:00 a.m. […]

• Immediate jeopardy, isolatedF689Sep 25, 2023

  Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 2 of 11 residents (Resident #6 and CR #7) reviewed for accidents in that: -The facility failed to implement Resident #6 care plan to monitor resident to prevent fall from wheelchair developing a right frontal contusion and displaced fracture of the right frontal calvarium (section of the skull). -The facility failed to take proper precautions when CR #7 who x-ray results revealed loss of normal cervical lordosis (improper alignment of the neck) experienced an unwitnessed fall. CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. […]

• Actual harm, isolatedF600Mar 20, 2026

  Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 9 residents (Resident #1) reviewed for abuse. Resident #2 was physically abusive to Resident #1 on 9/26/25 when he punched him with a closed fist in the face.These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress. The findings included:Resident #2Record review of Resident #2's admission Record generated on 3/19/26 revealed he was readmitted to the facility on [DATE] with diagnoses of encephalopathy (a syndrome of brain dysfunction caused by toxins, infections, metabolic imbalances, or trauma, leading to altered mental status, confusion, and cognitive deficits), aphasia (inability or impaired ability to understand… […]