Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cypress Grove Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently provide hot foods at a palatable temperature, particularly for residents receiving in-room meal service. Multiple residents reported that cooked foods were lukewarm, sometimes cold, or not always cooked thoroughly when delivered to their rooms, and several residents at a Resident Council meeting echoed that food was not always warm during in-room dining. This occurred despite the facility’s policy and the Dietary Manager’s statement that all hot and cold food items must be served at an adequate, palatable temperature and that resident food preferences would be accommodated.
A resident with breast cancer, prescribed daily exemestane 25 mg, was found with a medication cup at the bedside containing a small white pill she could not identify. Review of the medication cart confirmed the pill was exemestane. Although the resident was documented as cognitively intact and independent for eating, the DON acknowledged there was no completed self-administration of medications assessment for this resident, despite facility policy requiring a nurse-conducted Self-Administration of Medication Assessment and approval before any resident self-administers medications.
The facility failed to ensure accurate completion of MDS assessments for two residents, leading to incorrect coding of antidepressant use and falls. For one resident with Alzheimer’s disease and major depressive disorder, the quarterly MDS indicated antidepressant use during the lookback period despite no active physician order or eMAR documentation of antidepressant administration. For another resident with dementia, the quarterly MDS coded one fall with no injury since the prior assessment, although the clinical record contained no fall documentation and the Administrator confirmed no fall occurred. The Regional Clinical Nurse reported that the MDS Coordinator had reviewed the wrong dates when coding these sections.
A resident with paraplegia and moderate cognitive impairment, dependent on staff for transfers and using a manual wheelchair, was observed alone in a courtyard sitting in direct sunlight without a drink, contrary to his care plan interventions. The resident reported being routinely left outside unattended, without a way to call staff, and not being offered sunscreen when outside. The care plan called for encouraging fluids, supplying and assisting with sunscreen, and offering assistance in and out of doors, but an RN acknowledged there was no monitoring system or set check times while the resident was outside and that there was no physician order for sunscreen available to offer.
Surveyors found that two cognitively intact residents, one with hypertension and one with dementia, did not receive showers on multiple days listed on their individualized shower schedules, despite one resident having previously filed a grievance about not getting showers and preferring showers over bed baths. Review of electronic and paper shower records showed several missed scheduled shower days for each resident, and documentation also noted that one resident refused a shower when it was offered outside his preferred time. These findings showed that staff did not consistently provide bathing on scheduled days in accordance with residents’ assessed needs, preferences, and stated rights.
Surveyors found that staff failed to accurately document a resident’s ongoing purple discoloration on the buttocks despite physician orders and a care plan requiring weekly skin assessments and documentation of abnormal findings, and despite prior hospital documentation of the discoloration. In addition, staff did not accurately document administration of calcitonin-salmon nasal spray for another resident, recording doses as given to the wrong nostril on multiple occasions, even though the DON reported the medication was being administered as ordered. These practices were inconsistent with the facility’s documentation policy requiring accurate, organized entries for skin assessments and medication administration.
A resident with COPD, obesity, and obstructive sleep apnea received ongoing O2 therapy via nasal cannula, with multiple progress notes documenting use of 2–3 LPM and staff reporting continuous oxygen use and CNA management of oxygen tanks, but no practitioner orders for oxygen application or equipment maintenance were found in the clinical record for several months. The care plan referenced administering oxygen as ordered, yet the admission MDS did not code oxygen therapy, and the DON acknowledged believing there had been an admission order while also stating the facility lacked its own oxygen therapy policy and instead followed a supplier’s policy. The deficiency was cited under 3.1-47(a)(6).
The facility failed to ensure that residents who required assistance with ADLs received showers as per their care plans. Six residents with various medical conditions and cognitive impairments experienced irregular shower schedules and incomplete documentation. Despite efforts to improve, the facility lacked an effective policy for ADL care or showers.
The facility failed to maintain a resident's dignity when a resident was observed fully exposed in bed with the door open. The resident, dependent on staff for care, was not wearing pants or an incontinence brief, and the situation was not immediately addressed by the staff present.
The facility failed to send necessary documents with a resident transferred to the hospital. The resident, with diagnoses including epilepsy and COPD, was transferred without the required transfer paperwork and bed hold policy. Interviews with staff confirmed the absence of proof that the transfer packet was sent, violating the facility's Hospital Transfer policy.
The facility failed to follow physician orders for two residents with feeding tubes, resulting in improper administration of nutritional feedings and lack of required documentation. One resident had outdated nutritional formula and improper head elevation, while another had enteral nutrition turned off without proper documentation.
The facility failed to ensure routine medications for a resident with GERD were available and dispensed according to physician's orders. Despite reordering the medications, they were not administered from May 12 through May 16 due to unavailability, and there was no documentation or follow-up actions taken to obtain them from the Emergency Drug Kit (EDK).
The facility failed to maintain accurate medical records for two residents. One resident's record incorrectly indicated participation in psychotherapy during a hospitalization, and another resident's record lacked documentation of departures and returns for medical procedures, contrary to facility guidelines.
Failure to Provide Palatable-Temperature Meals to Residents, Especially During In-Room Dining
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to reasonably accommodate resident food preferences regarding temperature of cooked foods, particularly for residents receiving meals in their rooms. In individual interviews, one resident stated the cooked food was lukewarm, another reported that cooked food was sometimes cold when it arrived to their room, and additional residents indicated that cooked food was cold at times, sometimes cold, or cold and not always cooked thoroughly when they ate in their rooms. During a Resident Council meeting, three anonymous residents also reported that food was not always warm when they ate in their rooms. The Dietary Manager stated that food must be served at an adequate temperature and with palatable taste and that resident food preferences were accommodated, and the facility’s Food Temperatures policy indicated that all hot and cold food items would be served at a palatable temperature at the time the resident receives the food. These resident reports and policy statements formed the basis for the cited deficiency under 410 IAC 16.2-3.1-3(v)(1). No additional clinical history or medical conditions for the residents involved were documented in the report.
Medication Left at Bedside Without Required Self-Administration Assessment
Penalty
Summary
Surveyors observed that a resident had a medication cup on the bedside table containing a small white round pill imprinted "111," and the resident stated she was unsure what the pill was. Review of the medication cart at that time identified the pill as exemestane 25 mg, a steroidal drug that had been ordered once daily since 10/9/23 for this resident, who had diagnoses including malignant neoplasm of the upper-inner quadrant of the left female breast. The most recent Quarterly MDS assessment indicated the resident was cognitively intact and independent for eating. During interview, the DON confirmed that the resident did not have a completed self-administration of medications assessment, despite facility policy requiring the nurse to evaluate and approve each resident who self-administers medications by completing a Self-Administration of Medication Assessment form before allowing self-administration. This failure to complete the required assessment occurred in the context of a medication being left at the bedside for the resident without documented evaluation of her ability to safely self-administer, as required by the facility’s Self Administration of Medications policy and 410 IAC 16.2-3.1-11(a).
Inaccurate MDS Coding for Medication Use and Falls
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect coding of antidepressant use and falls. For one resident with diagnoses including Alzheimer’s disease and major depressive disorder, the quarterly MDS dated 3/30/26 indicated the resident received an antidepressant during the 7‑day lookback period, but the clinical record contained no active physician order for an antidepressant and the electronic Medication Administration Record showed no administration of an antidepressant during that time. For another resident with dementia, the quarterly MDS dated 3/30/26 coded one fall with no injury since the prior assessment on 12/29/25, yet the clinical record contained no documentation of a fall during that interval, and the Administrator confirmed the resident did not fall in that period. During interviews, the Regional Clinical Nurse stated that both MDS assessments dated 3/30/26 for these residents were wrong because the MDS Coordinator looked at the wrong dates for the fall and antidepressant, while the Administrator stated that the facility followed Resident Assessment Instrument (RAI) guidelines to code MDS assessments.
Failure to Implement Care Plan for Resident Outside in Courtyard
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who liked to go outside in an unsecured courtyard area. During an observation, the resident was seen alone in his wheelchair in direct sunlight without a drink. In an interview shortly afterward, the resident reported that staff always left him outside unattended, that he had no way to notify staff when he was ready to return indoors, that he had not been offered sunscreen, and that he was ready to go back inside. The resident’s diagnoses included paraplegia, and his most recent Quarterly MDS showed he was moderately cognitively impaired, dependent on staff for transfers, and used a manual wheelchair for mobility. The resident’s care plan, in place since 2018, documented that he liked to go outside in an unsecured area, was not considered an elopement risk, had a BIMS score of 13, and had been educated to notify staff when outside and to remain on the sidewalk. Care plan interventions included encouraging the resident to have a drink of choice when outside, supplying sunscreen and assisting with its application when appropriate, and offering assistance in and out of doors. An RN stated there was no monitoring system or set time intervals for checking on the resident while he was outside unattended, and that staff often only told him a time limit for being outside. The RN also noted the resident was not wearing sunscreen because he often refused it previously, and the physician’s orders did not include an order for sunscreen to be available to offer. The facility’s Comprehensive Care Plan policy required periodic review and revision of care plan problems, goals, and interventions following each OBRA MDS assessment.
Failure to Provide Scheduled Showers for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing for residents who required staff assistance. For one resident with hypertension who was cognitively intact and required partial staff assistance for bathing, the clinical record showed a grievance had been filed stating she was not receiving her showers or having her hair washed. The grievance also noted that staff had been educated on her preference for a shower rather than a complete bed bath. Her shower schedule, updated on 4/1/26, listed Tuesday and Friday as her shower days, yet review of electronic and paper shower documentation showed she did not receive showers on several scheduled dates between 3/9/26 and 4/9/26, specifically on 3/10/26, 3/27/26, and 3/31/26. Another resident with dementia, who was cognitively intact per the admission MDS and required staff supervision during bathing, also did not receive showers on multiple scheduled days. His shower schedule, updated on 4/1/26, indicated Wednesday and Saturday as his shower days. Review of shower documentation from 3/11/26 to 4/9/26 showed missed showers on 3/14/26, 3/18/26, and 3/25/26. Documentation further indicated that this resident refused a shower on 4/8/26 because it was offered outside of his preferred shower time. The facility’s Residents Rights policy, revised 7/2023, stated that all staff members recognize the rights of residents at all times to enable personal dignity, well-being, and proper delivery of care, but the documented missed showers demonstrated that scheduled bathing was not consistently provided as planned.
Failure to Accurately Document Skin Assessments and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and timely documentation of skin assessments for one resident. During an observation of incontinence care, the resident was noted to have a large purple discoloration on both buttocks, and barrier cream was applied. The resident’s diagnoses included diabetes mellitus, hemiplegia, and a left below-knee amputation, and the MDS indicated the resident was cognitively intact and dependent on staff for several ADLs. Physician orders and the skin integrity care plan required weekly skin assessments, documentation of skin condition, and notification of the MD for abnormal findings. A hospital after-visit assessment documented a non-blanchable purple discoloration on the buttocks, but subsequent admission and weekly skin observations, including the most recent one, documented no skin discolorations. The RN and Wound Nurse later indicated the resident had purple discoloration on the buttocks since admission, but staff had not documented its presence. The facility also failed to ensure accurate documentation of medication administration for another resident receiving calcitonin-salmon nasal spray. The resident had chronic obstructive pulmonary disease and required setup assistance for eating. Physician orders directed calcitonin-salmon spray to be administered to alternating nostrils on different days. A pharmacy consult noted staff were not giving calcitonin spray as ordered and recommended staff education on proper administration. Review of the eMAR showed that staff documented administering the spray to the left nostril on some days when the order was for the right nostril, and to the right nostril on some days when the order was for the left nostril. The DON stated that staff were administering the calcitonin spray as ordered but were not documenting it correctly. The facility’s documentation policy required accurate, organized documentation of all resident information, including weekly skin and vital sign assessments and wound management entries.
Oxygen Therapy Provided Without Practitioner Orders or Facility Policy
Penalty
Summary
The facility failed to ensure a resident receiving oxygen therapy had practitioner orders for oxygen use and equipment maintenance. The resident had diagnoses including nontraumatic acute subdural hemorrhage, COPD, morbid obesity due to excess calories, and obstructive sleep apnea. An admission MDS was not coded for oxygen therapy, yet the care plan addressing potential impaired gas exchange related to COPD and sleep apnea included an approach to administer oxygen as ordered starting in mid-November. Progress notes documented multiple entries over several weeks indicating the resident was on oxygen via nasal cannula at 2–3 LPM, including notations that the resident used Bi-PAP or C-PAP and required or used oxygen. Despite this documented and ongoing use of oxygen therapy, a review of physician orders for November, December, and January revealed no orders for oxygen application or equipment maintenance in the clinical record. Staff interviews confirmed that the resident was treated as being on continuous oxygen therapy, with CNAs refilling oxygen tanks and applying oxygen when the resident was out of bed, and an LPN recalling the resident being on oxygen at admission and later believed to be weaned to C-PAP only. The DON stated she was almost certain the resident had been on continuous oxygen therapy and thought it was an admission order, and also reported that the facility did not have its own oxygen therapy policy, instead following the policy of the medical supply service. This deficiency was cited under 3.1-47(a)(6).
Failure to Provide Consistent Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers as per their care plans. This deficiency was identified for six out of seven residents reviewed for ADLs. The residents involved had various medical conditions and cognitive impairments, and their care plans specified the frequency and preference for showers, which were not consistently followed or documented by the staff. Resident 40, who had mild cognitive impairment and required partial to moderate assistance for bathing, reported receiving only one shower per week despite preferring three showers weekly. The Point of Care (POC) history indicated irregular shower schedules and several refusals, but no complete bed baths were documented. Similarly, Resident 46, with mild cognitive impairment and requiring substantial assistance, reported rarely receiving showers, and the POC history showed inconsistent shower records with no complete bed baths documented. Other residents, including Resident 20, Resident 12, Resident 19, and Resident 75, also experienced irregular shower schedules and incomplete documentation of showers or bed baths. The Director of Nursing (DON) acknowledged that partial bed baths were not an acceptable substitution for showers, and the Administrator admitted that the facility had been working on this issue for over a year. Despite efforts to improve documentation accuracy, the facility lacked a specific policy related to ADL care or showers, and the existing Resident Care/ADL Sheet policy was not effectively implemented.
Failure to Maintain Resident's Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity for Resident 75, who was observed fully exposed in bed with the bedroom door fully open. The incident occurred on 5/17/24 at 8:58 A.M., when Resident 75 was not wearing pants, an incontinence brief, or covered with a bedsheet. A Qualified Medication Aide (QMA) was present but did not address the situation, and it was only at 9:01 A.M. that a Certified Nurses Aide (CNA) responded to the resident's call light and provided an incontinence brief. Resident 75, who was admitted with diagnoses including acute respiratory failure with hypoxia, dysphagia, pneumonitis due to inhalation of food and vomit, and sepsis, was completely dependent on staff for toileting, bathing, and transfers. The resident was also receiving nutrition through a feeding tube. During an interview, a Registered Nurse (RN) indicated that residents should not be left exposed and that CNAs should seek a nurse to pause feedings before performing incontinence care. The facility's policy on Resident's Rights, dated 11/15, was reviewed and indicated that residents should be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and care for personal needs.
Failure to Send Required Transfer Documents with Resident
Penalty
Summary
The facility failed to ensure that necessary documents were sent to the hospital upon the transfer of Resident 80. The resident, who had diagnoses including epilepsy and COPD, was transferred to the hospital for evaluation. However, the nursing progress note from the day of transfer lacked documentation of sending the required transfer paperwork and bed hold policy. The hospital records confirmed that the medical transfer paperwork was incomplete, missing critical information such as the resident's code status. Interviews with facility staff, including RN 3 and the Director of Nursing, revealed that there was no proof that the transfer packet was sent with the resident on the day of the transfer. The facility's Hospital Transfer policy mandates that pertinent information about the resident and actions taken to receive treatment at a hospital must be properly documented and copies placed in the resident's record. This policy was not followed, as evidenced by the absence of the transfer and bed hold paperwork in Resident 80's medical records.
Failure to Follow Physician Orders for Tube Feedings
Penalty
Summary
The facility failed to ensure physician orders were followed and residents' nutritional feedings were administered correctly for two residents with feeding tubes. Resident 75 was observed with a feeding pump running at 75 mL per hour, but the nutritional formula bottle was dated from the previous day, and the gauze around the feeding tube was dated two days prior. Additionally, the head of the bed was not elevated as required, and there was a discrepancy between the CNA's and RN's accounts regarding the pausing of the feeding pump during incontinence care. Resident 75's clinical record indicated multiple serious diagnoses, including acute respiratory failure and dysphagia, and required continuous feeding and specific care for the feeding tube site, which were not adhered to as per physician orders. Resident 68 was observed with enteral nutrition running at 38 mL per hour while the head of the bed was flat, contrary to physician orders. The enteral nutrition was also found to be turned off at various times without proper documentation. Resident 68's clinical record showed significant medical conditions, including spastic quadriplegic cerebral palsy and profound intellectual disabilities, and required continuous feeding with specific instructions for the head of the bed elevation and feeding schedule. The facility's records lacked documentation of the enteral nutrition being turned off outside the prescribed times, and the facility's Enteral Therapy policy was not followed as required.
Failure to Administer Routine Medications
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for a resident diagnosed with gastro-esophageal reflux disease (GERD). The resident had orders for omeprazole and pantoprazole, both medications to treat acid reflux, which were not administered from May 12 through May 16 because the drugs were unavailable. The medications had been reordered from the pharmacy on May 10, but there was no documentation in the clinical record explaining the unavailability of the medications or any follow-up actions taken by the staff to obtain them from the Emergency Drug Kit (EDK), which had the medications in stock. Licensed Practical Nurse (LPN) 7 indicated that medications usually arrived the same day and that staff should call the pharmacy if they did not. The Director of Nursing (DON) confirmed that if a medication was unavailable, it should be given from the EDK and that staff should document the unavailability and follow up with the pharmacy. However, there was no such documentation in the clinical record for the resident's omeprazole and pantoprazole. The facility's policy on reordering, changing, and discontinuing orders required staff to review transmitted re-orders for status and potential issues, which was not adhered to in this case.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For Resident 14, the clinical record indicated participation in psychotherapy on a date when the resident was actually hospitalized, leading to an erroneous entry in the medical record. This discrepancy was confirmed during an interview with Social Services, who acknowledged the resident's hospitalization during the documented psychotherapy session. For Resident 75, the clinical record lacked documentation of the resident's departure and return to the facility for medical procedures on two separate days. Despite the resident being out of the building for an endoscopy and a colonoscopy, there was no record of these absences in the clinical documentation. The facility's own guidelines require accurate documentation of resident status upon leaving and returning to the facility, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Woodlands Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Hamilton Pointe Health And Rehab | 2.9 mi | ★★★★★ | 4 | 0 |
| Newburgh Health And Rehab | 3 mi | ★★★★★ | 29 | 0 |
| Majestic Care Of Newburgh | 3.1 mi | ★★★★★ | 0 | 0 |
| River Pointe Health Campus | 5.7 mi | ★★★★★ | 1 | 0 |
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