Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Point-skilled Nursing By Americare during CMS and state inspections, most recent first.
Food Storage and Sanitation Deficiencies: The facility failed to store and distribute food under sanitary conditions. Observations showed water on the floor around the ice machine with saturated mop heads placed underneath the air gap and no wet floor sign, unlabeled and undated opened food items in the freezer, dented soda cans and unlabeled cups of white sauce in the stand-up freezer, exposed dirty hand towels and an uncovered trash can in the dishwashing area, and dirt, debris, and food particles on the kitchen floors.
Surveyors observed multiple unaddressed maintenance and cleanliness issues, including unattached and missing trim, dirty and stained privacy curtains, cobwebs, debris in light fixtures, and unsanitary conditions in the shower room. Two residents requested curtain replacements due to visible stains, and staff interviews confirmed that cleaning and maintenance tasks were not consistently documented or addressed.
The facility failed to support the use of Seroquel for one resident because the chart lacked an appropriate diagnosis, target behaviors, behavior documentation, and pharmacist input, and staff stated dementia was not an appropriate diagnosis for the medication. The facility also failed to limit a resident’s PRN Xanax order to 14 days or document a clinical rationale for continuing it, and the MRR did not address the order.
Medication reconciliation and dating deficiencies were identified when an opened lorazepam bottle for a resident did not match the amount documented in the narcotic log, and two opened tuberculin vials were found undated in the med room. Staff stated narcotics should be counted each shift and opened bottles or vials should be dated, but the facility did not provide policies for narcotic reconciliation or dating medications when opened.
A resident with a CVAD receiving IV ampicillin for osteomyelitis did not receive EBP as staff accessed the line. An LPN cleaned the CVAD hub for only a few seconds, allowed it to touch the resident’s arm and wheelchair, and reconnected IV tubing without re-cleaning the hub after the infusion was interrupted. The same resident also received incontinent care from two nursing assistants who wore gloves but did not wear gowns, despite EBP signage and PPE being available outside the room.
Failure to inspect mobility rails was identified for three residents with no documented maintenance inspections. A resident with vascular dementia, COPD, and depression, a resident with dysphagia, hemiplegia, anxiety, depression, and a fall history, and a resident with diabetes, dementia, weakness, and a fall history all had U-shaped rails that moved with minimal effort. Staff, including the Maintenance Supervisor, RN L, the Administrator, and the DON, stated routine inspections were not being completed or documented.
A resident with multiple medical conditions who required supervision for transfers and toileting was left unattended in the bathroom for approximately nine hours after being assisted by staff. The resident attempted to transfer independently, resulting in a severe fall with a de-gloved hand, open wrist fracture, and head laceration. Staff did not consistently check on the resident, and facility policies lacked clear guidance on monitoring frequency, leading to the incident.
The facility failed to develop and implement comprehensive care plans for two residents. One resident with occlusion of bilateral carotid arteries and basal cell carcinoma had a wound not addressed in the care plan. Another resident with dementia had no interventions for dementia in their care plan. Interviews with staff confirmed these deficiencies.
A resident with occlusion of bilateral carotid arteries and basal cell carcinoma had a wound that was not accurately assessed or documented by the LTC facility. Despite a policy requiring regular skin assessments, there was no documentation of the wound's characteristics. Observations showed a large bandage on the resident's nose, and an LPN noted an opening by the lower eyelid. The ADON and DON confirmed that weekly assessments were required but not completed.
The facility failed to maintain sanitary conditions for food storage and distribution, risking cross-contamination and food-borne illness for all residents. There were significant lapses in documenting refrigerator and freezer temperatures, dishwashing machine operation, and sanitizer concentration levels during August and September 2024. Staff interviews confirmed these tasks were expected to be completed daily, but documentation was lacking.
The facility failed to properly implement enhanced barrier precautions for four residents, as observed by surveyors. An LPN wore improperly fitting gowns during wound and catheter care, causing them to fall to the elbows. Another LPN did not wear a gown while checking a gastrostomy tube. Staff interviews revealed a lack of awareness and understanding of proper PPE use during specific care activities.
The facility failed to maintain a clean and safe environment, with observations of cobwebs and dirt on ceilings and light fixtures outside various exit doors. Residents noticed the unclean conditions, and staff interviews revealed a lack of clarity in cleaning responsibilities. The Maintenance Supervisor acknowledged responsibility for the outside environment, but the facility's policy was not followed, affecting all 68 residents.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions. Observations in the kitchen ice machine area showed visible water on the floor in front of and underneath the ice machine, two saturated mop heads lying underneath and around the air gap on the floor, and no wet floor signage. The facility did not provide a policy addressing the ice machine, kitchen floor cleaning, dented cans, or use of trash cans. During interviews, the Assistant Dietary Manager and the Administrator stated that dirty mop heads should be removed and taken to laundry, floors should be free of food particles and debris, opened foods and containers should be labeled and dated, and nothing should be placed around or under the ice machine air gap to soak up water. Additional observations in the kitchen showed an undated and unlabeled open ziplock bag of shredded lettuce and an undated and unlabeled open bag of purple shredded cabbage in the walk-in freezer. The stand-up freezer contained two dented soda cans and 10 undated and unlabeled small plastic cups with white sauce. In the dishwashing area, two plastic knives, a rolled-up paper napkin, a small plastic container, and debris were on the floor beside the trash can; a plastic container of exposed dirty hand towels had no lid; and a trash can with exposed food and debris had no lid next to the trash disposal counter, with no staff present. Kitchen floors also had a build-up of dirt, debris, and food particles underneath the steam food table and the cold food table.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of unaddressed maintenance and cleanliness issues throughout the building. Surveyors noted unattached and missing baseboard trim near the kitchen's ice machine and behind the linen cart area, visible cobwebs on a sprinkler head and light fixtures, several light fixtures with insects, dirt, and debris, and missing protective covers on light fixtures near the laundry room and resident rooms. Privacy curtains in several rooms were stained and dirty, with two residents specifically requesting that their curtains be replaced due to visible stains and a lack of replacement over several years. The facility did not provide a policy for maintaining a homelike environment, and the maintenance repair log showed no areas of concern addressed over a five-month period. Further observations in the bath/shower room revealed unsanitary conditions, including containers with unknown liquids, a disposable razor, a wet washcloth, dirty gloves on the floor, a trash can without a lid containing dirty items, a saturated towel, and food and drink items left on the shower cart. There was also a strong smell of urine, and the room was not in use at the time. Staff interviews confirmed that the shower room should be cleaned and sanitized after use, and that maintenance and housekeeping issues were typically reported verbally rather than documented. The Maintenance Supervisor and Administrator were aware of some issues, such as the baseboard trim, but there was a lack of documentation and follow-up on daily maintenance tasks.
Unnecessary Psychotropic Medication Use and Missing PRN Duration Limits
Penalty
Summary
The facility failed to provide an appropriate diagnosis for the use of Seroquel for one resident with diagnoses including Alzheimer's disease, pneumonia, COPD, and difficulty walking. The resident had an order for Seroquel 25 mg by mouth at bedtime related to unspecified dementia, but the medical record contained no documentation of an appropriate diagnosis for the medication, no identified target behaviors, no documentation of any behaviors, and no pharmacist recommendations addressing the diagnosis for Seroquel. Staff interviews confirmed that dementia was not an appropriate diagnosis for Seroquel, and the consultant pharmacist and medical director also stated that dementia was not an appropriate diagnosis for the medication unless prescribed by a psychiatric physician. The facility also failed to monitor the drug regimen for another resident by not ensuring a PRN psychotropic medication order was limited to 14 days unless a specific duration and clinical rationale were provided. That resident had vascular dementia, COPD, and major depressive disorder, and had an order for Xanax 0.25 mg by mouth every 4 hours PRN for anxiety. The pharmacist did not address the PRN Xanax order in the medication regimen review, there was no request for a clinical rationale to continue the medication beyond the 14-day time frame, and the medical record contained no clinical rationale from the physician for the PRN Xanax order. Staff interviews stated that PRN psychotropic medication orders should have a 14-day stop date.
Medication Reconciliation and Dating Deficiencies
Penalty
Summary
The facility failed to implement procedures to ensure medications were accurately reconciled for one resident, who had an order for lorazepam 0.5 ml every 8 hours for agitation related to anxiety. During observation of the locked medication refrigerator in the main medication room, an opened 30 ml bottle of lorazepam 2 mg/ml for the resident was found with 16 ml remaining. However, the resident’s lorazepam narcotic reconciliation log showed that on-coming and off-going staff documented 19 ml remaining in the bottle, and staff documented that the medication was counted each shift. The facility also failed to ensure vials of tuberculin were dated when opened. During observation of the main medication room, two opened and undated vials of tuberculin were found. Staff interviews indicated that narcotic medications should be counted each shift by on-coming and off-going staff, that medication bottles and vials should be labeled with the date opened, and that undated vials should be discarded. The facility did not provide a policy regarding narcotic reconciliation or dating of medications when opened.
Failure to Follow Enhanced Barrier Precautions During CVAD Care and Incontinent Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a central venous access device (CVAD) and receiving IV ampicillin for osteomyelitis. During observation of medication administration, an LPN entered the resident’s room with gown and gloves on, removed the cap from the CVAD line, cleaned the hub with an alcohol pad for three seconds, flushed the line, and then allowed the hub to dangle and touch the resident’s right arm. The LPN did not clean the hub before connecting the IV tubing, and when the infusion was stopped because the medication was not infusing correctly, the hub rested against the resident’s wheelchair and was reconnected without being cleaned again. RN and ADON interviews stated the hub should be cleaned for at least 10 seconds. The facility also failed to follow EBP during incontinent care for the same resident. Although signage on the resident’s door instructed staff to wear gown and gloves and PPE was available outside the room, two nursing assistants entered the room, performed hand hygiene, and put on gloves only; they did not wear gowns while providing incontinent care. One CNA stated staff did not have to wear a gown for the resident and believed the EBP signage was for the roommate, while an LPN stated staff should always wear a gown and gloves when caring for the resident. The DON stated the EBP signage should have been for both the resident and the roommate.
Failure to Inspect Mobility Rails
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and side rails for three residents, and no maintenance inspection was documented for the mobility rails in their rooms. The facility policy titled, Side Rail Inspection, required regular inspections to ensure the rails were securely attached to the bed frame, functioned properly, and had no broken, bent, missing, or unsafe parts. However, review of the records for Residents #8, #11, and #28 showed no maintenance inspection for the mobility rail for any of the three residents. Resident #8 had diagnoses of vascular dementia, COPD, and major depressive disorder, and observations showed a U-shaped mobility rail in the upright position on both sides of the bed that moved with minimal effort. Resident #11 had diagnoses of dysphagia, hemiplegia affecting the dominant side, anxiety, major depressive disorder, and a history of falling; observations showed a U-shaped mobility rail in the upright position on both sides of the bed that moved with minimal effort, and the resident stated he/she used both rails to try to turn over in bed. Resident #28 had diagnoses of diabetes mellitus, dementia, major depressive disorder, generalized weakness, and a history of falls; observations showed a U-shaped mobility rail in the upright position on the right side of the bed that moved with minimal effort, and the resident stated he/she used the rail to get up and go to the bathroom at night. During interviews, the Maintenance Supervisor said nursing was responsible for the mobility rails, RN L said no formal inspection was completed or documented, the Administrator said the facility did not do routine inspections on the mobility rails, and the DON said he was not aware inspections needed to be made unless staff reported an issue.
Failure to Provide Adequate Supervision Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to ensure the safety of a resident who required assistance with activities of daily living, including toileting and transfers. The resident, who had multiple medical diagnoses such as coronary artery disease, heart failure, chronic kidney disease, and hypertension, was assessed as needing supervision or touch assistance for transfers and toileting. Despite these needs being documented in the care plan, staff assisted the resident to the toilet but did not check on them for approximately nine hours. During this time, the resident attempted to transfer independently, resulting in a severe fall and injury. The incident was discovered when staff found the resident lying on the bathroom floor, partially clothed, with significant injuries including a de-gloved hand, open fractured wrist, and a laceration to the forehead. The resident reported attempting to get off the toilet, slipping, and getting their wrist stuck in the handrail before falling to the floor. The call light was not activated, and the resident stated they yelled for help but were not heard. Staff interviews revealed inconsistent accounts of when the resident was last seen, with some staff recalling seeing the resident on the toilet but not returning to check on them, and others unable to confirm who assisted the resident initially. Facility policies reviewed did not include specific guidance on monitoring residents throughout the night or the frequency of checks required. The care plan indicated the need for frequent checks and supervision, but this was not implemented. Staff and leadership interviews confirmed that the resident was known to be private and typically used the call light for assistance, but there was no documentation of a request for privacy on the care plan. The lack of supervision and failure to follow the care plan directly led to the resident being left unattended for an extended period, resulting in serious injury.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans with specific interventions for two residents. Resident #12, who was admitted with diagnoses of occlusion of bilateral carotid arteries and basal cell carcinoma of the skin, was observed with a large bandage covering the nose. However, the care plan revised earlier in the month did not address wound care interventions. This oversight was confirmed during interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who both acknowledged that any wound should be addressed in the care plan. Similarly, Resident #63, admitted with a diagnosis of dementia, had a care plan that did not include interventions for dementia. During an interview, an LPN noted a significant wound near the resident's lower eyelid, which was not addressed in the care plan. The ADON and the Minimum Data Set (MDS) Coordinator confirmed that a diagnosis of dementia should be included in the care plan with appropriate interventions. These deficiencies highlight the facility's failure to ensure that care plans are comprehensive and tailored to the residents' specific medical needs.
Failure to Document and Assess Resident's Wound
Penalty
Summary
The facility failed to accurately assess and document a wound for a resident, identified as Resident #12, which was a deficiency in meeting professional standards of quality. The facility's policy required a full body skin assessment by a licensed or registered nurse upon admission, daily for three days, and as needed, with any changes reported to the charge nurse. However, there was no documentation of skin assessments related to the resident's wound, including the type, measurements, characteristics, color, and odor. The resident had diagnoses of occlusion of bilateral carotid arteries and basal cell carcinoma of the skin, and there was an order for Mupirocin ointment to be applied to the nose for drainage, but the care plan did not address wound care interventions. Observations and interviews revealed further deficiencies. On a specific date, the resident was observed with a large bandage covering the nose, and an LPN noted an opening by the lower eyelid the size of a dime. The Assistant Director of Nursing stated that weekly assessments should be completed for residents with wounds, and the Director of Nursing confirmed that wound assessments should be done weekly on active wounds. The lack of documentation and assessment of the resident's wound indicates a failure to adhere to the facility's policy and professional standards of care.
Failure to Maintain Sanitary Food Storage and Distribution
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, which increased the risk of cross-contamination and food-borne illness for all 68 residents. The facility's policies required daily documentation of refrigerator and freezer temperatures, dishwashing machine operation, and sanitizer concentration levels. However, there were significant lapses in documentation for these critical tasks during August and September 2024. Specifically, there were 18 missed opportunities for recording dishwasher temperatures, 29 missed opportunities for refrigerator temperature logs, and 16 missed opportunities for checking sanitizer concentration levels. Interviews with facility staff, including a Dietary Aide, the Dietary Manager, and the Administrator, confirmed that these checks were expected to be completed and documented daily. The Dietary Manager acknowledged the hiring of new staff and the need to remind them to complete these tasks. The Administrator also expressed the expectation that dietary staff should document these checks daily and sign off upon task completion. Despite these expectations, the lack of documentation indicates a failure to adhere to established procedures, potentially compromising food safety.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow enhanced barrier precautions (EBP) for four residents during care, as observed by surveyors. For Resident #12 and Resident #13, the Licensed Practical Nurse (LPN) C wore an isolation gown that did not fit properly, causing it to fall to the elbows during wound treatment. This improper fit of the gown was acknowledged by LPN C, who stated that the gowns were too small and did not fit around the shoulders. Similarly, during the care of Resident #35, LPN C's gown fell to the elbows while performing suprapubic catheter care, and the resident's brief and pants were allowed to lay back on the catheter insertion site multiple times during the procedure. For Resident #56, LPN D did not wear an isolation gown while checking the residual and placement of a gastrostomy tube, despite the presence of an open area that could leak body fluids. Interviews with staff, including the Infection Preventionist (IP), Registered Nurse (RN) E, and the Assistant Director of Nursing (ADON), revealed a lack of awareness and understanding of the proper use of gowns and PPE during specific care activities. The facility had recently started implementing the EBP, and there was ongoing coordination with the Medical Director for further clarification on its implementation.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment, as evidenced by the buildup of cobwebs and dirt on the vinyl ceilings and light fixtures outside various exit doors. Observations were made over several days, showing consistent neglect in cleaning these areas, which included locations near resident rooms, the laundry door, the tv/living room, the bird aviary room, the Rehab-to-Home wing, and the main entrance/exit door of the facility. This deficiency was noted to potentially affect all 68 residents in the facility. Interviews with residents and staff revealed that the cobwebs and dirt had been present for some time. Residents expressed their awareness and concern about the unclean conditions, while the housekeeper clarified that their duties were limited to the inside of the building. The Maintenance Supervisor acknowledged responsibility for the outside environment, and the Administrator confirmed the expectation for regular cleaning of these areas. Despite these acknowledgments, the facility's policy on maintaining a safe and sanitary environment was not adhered to, leading to the observed deficiencies.
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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 Dexter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memory Lane Of Dexter | 0.4 mi | ★★★★★ | 0 | 0 |
| Crowley Ridge Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Prairie View Skilled Nursing | 6.4 mi | ★★★★★ | 0 | 0 |
| Winchester Nursing Center, Inc | 8.9 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Malden | 15.3 mi | ★★★★★ | 0 | 0 |
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