Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Valley Center For Nursing And Rehabilitati during CMS and state inspections, most recent first.
The facility did not provide the required 8 hours of RN coverage on three occasions when the scheduled RN called out and no replacement was arranged. Staffing records and interviews with the DON and Administrator confirmed that no RN was available to cover these shifts, resulting in a lack of RN coverage for the entire 24-hour period.
Surveyors identified deficiencies in the Dietary Department, including improper storage, labeling, and dating of food items, failure to dispose of expired foods, and not following manufacturer storage instructions. Two dietary staff members, including the manager, were observed preparing food without proper beard restraints or full hair coverage. Additionally, kitchen equipment such as the fryer and stove had significant grease build-up, indicating inadequate cleaning practices.
Surveyors identified that several residents' MDS assessments were inaccurately coded, including failure to document antibiotic administration, PASRR Level II status, range of motion impairment, and the correct source of admission or re-entry. These errors were confirmed through record review, staff interviews, and direct observation, and involved both clinical and administrative staff.
The facility did not ensure that care plans were reviewed and updated by the IDT after MDS assessments, nor did it involve two residents or their representatives in the care planning process. Both residents, who were cognitively intact and required significant assistance with daily living, were not invited to participate in care plan meetings after their initial conferences, and staff confirmed that ongoing care plan reviews and meetings for long-term residents were not conducted.
A resident with left-hand contractures and a history of traumatic brain injury did not have a physician-ordered splint applied as required, despite care plans and staff training. Multiple observations showed the splint was not in use, and staff interviews revealed confusion about responsibility for its application. Documentation indicated skin checks were performed, but the splint was not consistently applied as ordered.
A resident with a history of traumatic brain injury and stroke struck another resident with severe cognitive impairment on the forehead after being blocked from exiting their shared room. The incident was witnessed by staff, resulting in a minor injury to the resident who was struck. There was no prior history of altercations between the two residents, and the event was reported to authorities.
The facility failed to properly date and discard opened multi-dose insulin pen injectors and remove expired medications in two medication carts. Additionally, loose pills were found in three medication carts, with staff failing to clean and check the carts before their shifts. Nurses acknowledged their responsibility for these tasks but admitted to not performing them during their shifts.
The facility failed to manage food storage and cleanliness, with expired and unlabeled foods found in refrigerators and storage areas. Kitchen appliances and storage areas were not cleaned regularly, leading to grease and food particles accumulation. The dietary manager and staff did not follow cleaning schedules, resulting in unsanitary conditions.
The facility failed to maintain secure and safe handrails in three halls, with observations noting broken, cracked, and missing end caps. Despite staff and residents using these handrails, they remained unrepaired, posing potential hazards. The Maintenance Director, new to the position, was unaware of the repair system, and the Administrator acknowledged the need for immediate audits and repairs.
The facility failed to maintain a clean and safe environment for residents, with multiple rooms found in unsanitary conditions and structural issues noted. Staffing shortages significantly impacted the housekeeping staff's ability to perform thorough cleaning, as reported by the staff and acknowledged by the housekeeping director. The maintenance director was unaware of the facility's environmental needs, and the administrator confirmed that recent staffing changes affected their ability to maintain cleanliness and structural integrity.
The facility did not meet the requirement for 8-hour RN coverage on 14 days, as revealed by staffing data and assignment schedules. The DON noted issues with RN coverage during the transition from agency staff, while the Scheduler cited call-outs as the cause of gaps. The Administrator was unaware of these call-outs and stressed the need for communication about RN coverage issues.
A resident with a right femur fracture and other conditions was discharged from an LTC facility without proper discharge planning. The facility did not conduct a discharge planning meeting or prepare necessary paperwork, resulting in the resident leaving without home health services or prescriptions. The family was not informed of the discharge process and had to arrange for services themselves, leading to a delay in care. The absence of a social worker contributed to the failure in implementing the discharge process.
A facility failed to complete a recapitulation of stay for a resident discharged to the community. The resident had multiple diagnoses, including a right femur fracture and chronic obstructive pulmonary disease, with intact cognition. The discharge summary was not completed due to the absence of a social worker, and the Director of Nursing was unsure why the recapitulation was not done.
The facility inaccurately coded MDS assessments for two residents, leading to deficiencies in cognitive patterns and medication documentation. One resident's cognitive status was not properly assessed, while another was incorrectly documented as receiving an insulin injection instead of a TB test. The MDS nurse and Administrator acknowledged these errors.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on three specific days during the review period. Payroll Based Journal (PBJ) staffing data and daily assignment sheets confirmed that on these dates, the RN scheduled to work called out and was not replaced, resulting in no RN coverage for the entire 24-hour period. At the time, the facility only employed two RNs, and the other RN was unavailable to cover the shifts. Both the Director of Nursing (DON) and the Administrator verified that there was no RN coverage on the identified dates.
Deficiencies in Food Storage, Labeling, Hygiene, and Kitchen Cleanliness
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's Dietary Department related to food storage, labeling, and hygiene practices. During initial and follow-up tours, several food items in the walk-in cooler, dry storage room, and walk-in freezer were found to be improperly stored, including opened bags of parsley, ham, cheese, margarine, taco seasoning, chicken breast strips, and breadsticks that were not sealed or dated as required. Some food items were also found to be expired, such as boxes of thickened sweetened tea and honey mustard dressing, and were not disposed of in a timely manner. Additionally, certain food products, including bread and croissants, were not stored according to the manufacturer's instructions, with items labeled for frozen storage being kept in the cooler or at room temperature instead. Dietary staff were observed not adhering to professional standards for personal hygiene. Two staff members, including the Dietary Manager and a Dietary Aide, were seen working in food preparation areas without proper beard restraints, and the hairnet worn by the Dietary Manager did not fully cover all hair. On a subsequent observation, the Dietary Manager was seen with his beard restraint positioned incorrectly, exposing facial hair while assisting with the tray line. The Regional Director of Dietary Services confirmed that all hair, including facial hair, should be covered while working in the Dietary Department. The cleanliness of kitchen equipment was also found to be lacking. The deep fat fryer and stove/oven had visible, sticky, dark brown grease build-up on their surfaces, indicating that cleaning schedules were not being followed. The Regional Director of Dietary Services acknowledged that these issues should have been addressed through routine cleaning and daily rounds. The facility's Administrator was informed of these findings during an interview.
Inaccurate MDS Coding for Medications, PASRR Status, Range of Motion, and Admission Source
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for multiple residents in several key areas, resulting in deficiencies. For one resident with diabetes and cirrhosis, the MDS did not reflect the administration of an antibiotic (rifaximin) during the 7-day look-back period, despite documentation in the Medication Administration Record and confirmation by MDS staff that the medication was given. Another resident who was hospitalized for sepsis and re-entered the facility was incorrectly coded as having entered from another nursing home, rather than from a hospital, due to reliance on pre-populated fields and lack of verification by the Social Service Director. A resident with schizoaffective disorder and a PASRR Level II determination was not accurately coded on the MDS to reflect this status, even though the care plan and PASRR documentation confirmed the requirement for specialized services. The MDS nurse acknowledged the omission, attributing it to assessments being completed by remote staff. Additionally, a resident with dementia and contractures was incorrectly coded as having no upper extremity impairment, despite care plan documentation and direct observation of contractures in the left hand and wrist. The MDS nurse admitted this was an oversight, and the administrator confirmed the coding error regarding range of motion. These inaccuracies were identified through staff interviews, record reviews, and direct observation, affecting four out of twenty-one residents whose MDS assessments were reviewed. The deficiencies involved failure to accurately document antibiotic use, PASRR Level II status, range of motion impairment, and the correct discharge location prior to admission or re-entry, as required by regulatory standards.
Failure to Review and Update Care Plans with Resident Participation After MDS Assessments
Penalty
Summary
The facility's Interdisciplinary Team (IDT) failed to review and update care plans following annual and quarterly Minimum Data Set (MDS) assessments and did not involve residents or their representatives in the care planning process for two sampled residents. For one resident with diabetes mellitus type 2 and congestive heart failure, records showed no evidence of IDT review or resident/family participation in care plan meetings after the most recent quarterly MDS. The resident confirmed not being invited to any care plan meetings, and staff interviews revealed a lack of awareness and implementation of required care plan reviews and meetings for long-term residents. Similarly, another resident with poly-osteoarthritis, dementia, and hypothyroidism had not participated in a care plan meeting since an initial conference, despite being cognitively intact and dependent on staff for daily activities. Documentation did not show IDT review or resident/family involvement in care plan updates after the most recent comprehensive annual MDS. Staff interviews confirmed that only initial care plan meetings were being conducted for new admissions, and ongoing care plan reviews and meetings for long-term residents were not held as required.
Failure to Apply Ordered Splint for Contracture Management
Penalty
Summary
A deficiency occurred when staff failed to apply a left-hand splint as ordered for a resident with contractures. The resident, who had diagnoses including dementia, contractures of the left wrist and hand, and a history of traumatic brain injury, was care planned and had physician orders to wear a left-hand splint for 4-6 hours daily, with skin checks to be performed after removal. Occupational therapy had previously worked with the resident, and at discharge, the resident was able to tolerate the splint for the required duration. The care plan and restorative program staff were trained to apply the splint, and the resident was dependent on staff for all ADLs. Despite these orders and care plans, multiple observations over several days revealed that the resident was not wearing the splint during various times of the day, both in bed and in a wheelchair. Staff interviews indicated confusion regarding responsibility for applying the splint, with some staff believing it was the responsibility of therapy staff, while others stated that nursing or restorative staff should apply it. The splint was found in the resident's nightstand drawer, and staff did not apply it or notify others about its absence from the resident's hand. Documentation in the Medication Administration Record indicated that skin checks were being documented as completed, but direct observations contradicted this, as the splint was not being applied as ordered. Interviews with the DON and Administrator confirmed that nursing staff were responsible for applying the splint daily, but this was not being carried out in practice, resulting in a failure to follow physician orders and care plan interventions for contracture management.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a resident was not protected from resident-to-resident abuse. The incident involved one resident, who was cognitively intact but had a history of traumatic brain injury and stroke, striking another resident on the forehead with his fist. The altercation happened as the first resident attempted to exit their shared room in his wheelchair but was blocked by the other resident's geri-chair. The resident who was struck had severe cognitive impairment, dementia with psychotic disturbance, and a history of physical aggression toward staff, but no prior behavioral concerns with other residents were documented. The event was directly observed by nursing staff, who immediately separated the two residents. The resident who was struck sustained a raised red area on his forehead and was later evaluated in the emergency room, where a CT scan was negative for acute injury. The resident who initiated the altercation admitted to hitting the other resident because he was blocked and felt ignored. There was no documentation of previous altercations or arguments between these two residents prior to this incident. Care plans for both residents noted their respective cognitive and behavioral histories, but there was no indication of prior issues between them. The incident was reported to the appropriate authorities, and both residents' representatives were notified. The deficiency was identified as a failure to protect a resident from abuse by another resident, as required by regulations.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to the handling and storage of medications. During observations, it was noted that opened multi-dose insulin pen injectors were not dated in two of the four medication administration carts, specifically in the Lower A and Lower B halls. Additionally, an expired multi-dose insulin pen injector was found in the Lower A hall cart. Nurses interviewed during the survey indicated that they were responsible for discarding opened and undated multi-dose vials and for checking the dates of opening on insulin pens at the beginning of their shifts. However, they admitted to not having checked the dates during their current shifts. Furthermore, the survey revealed that loose pills were found in the medication administration cart drawers in three of the four carts observed, located in the Lower A hall, and Upper and Lower B halls. The nurses and medication aide responsible for these carts were unable to identify the loose pills and acknowledged that they had not cleaned the carts before their shifts, despite being responsible for checking and cleaning the medication carts each shift. The Director of Nursing confirmed that all nurses were expected to date multi-dose medication containers, check for expired medications, and ensure no loose pills were left in the carts.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly manage and maintain food storage and cleanliness in the kitchen and storage areas, leading to potential health risks for residents. Observations revealed expired foods and improperly labeled items in the reach-in refrigerator, walk-in refrigerator, and dry storage area. The dietary cook and manager acknowledged that leftover foods should be discarded within a specific timeframe, but several items were found without proper labeling or past their expiration dates. Additionally, personal items were improperly stored in the facility's refrigerators. The facility also failed to maintain cleanliness in various kitchen areas, including the stove, oven, deep fryer, and silverware holder. Observations showed grease and food particles on these appliances, and the dietary manager admitted that cleaning schedules were not adequately followed. The walk-in refrigerator and freezer floors were found with debris and spills, indicating a lack of regular cleaning. The dietary manager and staff were responsible for cleaning these areas, but the cleaning was not performed as required. Interviews with the dietary manager and regional director revealed inconsistencies in cleaning schedules and responsibilities. The dietary manager was responsible for ensuring daily and weekly cleaning tasks were completed, but there was no documentation for daily cleaning schedules. The regional director emphasized the importance of proper labeling and discarding of food, as well as maintaining cleanliness in the kitchen. The administrator confirmed that the dietary manager was accountable for overseeing these tasks and ensuring compliance with the facility's standards.
Handrail Deficiencies in Facility Corridors
Penalty
Summary
The facility failed to ensure that handrails in the corridors were properly secured, repaired, and free from sharp edges across three halls. During an observation on June 17, 2024, it was noted that the handrails in the A hall were in need of repairs due to being broken, cracked, and missing end caps. These issues were observed in the corridor joining the A facility hall bathroom and several resident rooms, as well as the resident shower room. The sharp edges of the handrails, due to missing end caps, posed a potential hazard as staff and residents were seen using them in their current condition. Further observations on the same day revealed similar issues in the C hall and B hall, where handrails were also broken, cracked, and missing end caps. These conditions were noted in corridors joining various rooms and areas, including storage and medical supply rooms. A follow-up observation on June 19, 2024, confirmed that the handrails remained unrepaired, and staff and residents continued to use them. The Maintenance Director, who had recently started, was unaware of the facility's repair system and had not yet addressed these issues. The Administrator acknowledged the responsibility of the Environmental Service Director and Maintenance Director in ensuring repairs for resident safety.
Facility Fails to Maintain Clean and Safe Environment Due to Staffing Shortages
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents across three halls, as observed during a survey. Multiple rooms were found with sticky floors, leftover food, paper products, and stains, indicating a lack of regular cleaning. Additionally, structural issues such as holes in walls and detached baseboards were noted, further compromising the safety and comfort of the residents. Interviews with housekeeping staff revealed that staffing shortages significantly impacted their ability to perform thorough cleaning. Housekeepers reported being unable to complete all assigned rooms, especially when deep cleaning was required. The housekeeping director acknowledged the staffing issues and admitted to not being able to follow up on cleaning schedules due to the need to fill in for absent staff. The maintenance director, who had recently started, was unaware of the facility's environmental needs and had not yet established a system for ensuring repairs were completed. The administrator confirmed that the environmental service director and maintenance director were responsible for maintaining cleanliness and structural integrity, but recent staffing changes had affected their ability to perform these duties effectively.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on 14 out of 123 days reviewed. Specifically, the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 2, 2024, indicated no RN coverage on six specific dates in March 2024. Additionally, daily assignment schedules from May 17, 2024, through June 17, 2024, showed a lack of 8-hour RN coverage on eight specific dates in June 2024. During interviews, the Director of Nursing (DON) mentioned that staffing schedules were managed by the Scheduler and acknowledged issues with RN coverage as the facility phased out agency staff. The Scheduler confirmed awareness of the 8-hour RN coverage requirement and stated that RNs were scheduled, but call-outs led to coverage gaps. The Administrator expressed an expectation for 8-hour consecutive RN coverage daily and noted that she was not informed of the call-outs by the Scheduler, emphasizing the need for communication regarding RN coverage problems.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident who was reviewed for discharge to the community. The resident, who had diagnoses including a right femur fracture and chronic pulmonary obstruction disease, was admitted to the facility and required one-person assistance with activities of daily living. Despite the resident's intact cognition and expressed desire to return home, the facility did not initiate active discharge planning at the time of admission or prior to discharge. The admission Minimum Data Set (MDS) assessment and care area assessment did not trigger a discharge plan, and there was no documentation in the care plan regarding the resident's discharge to the community. The discharge process was inadequately managed, as evidenced by the lack of a discharge planning meeting with the resident, family, and interdisciplinary team. The family was informed of the discharge date by the insurance company, not the facility, and was not provided with necessary information or services at the time of discharge. The resident was discharged without a prepared discharge packet, including home health services, prescriptions, or home care instructions. The family had to contact the facility the following day to obtain prescriptions and a contact for home health services, resulting in a delay of three weeks before the resident received home health or therapy services. Interviews with facility staff, including a nurse, nurse practitioner, rehab director, and director of nursing, revealed a lack of communication and coordination in the discharge process. The absence of a social worker contributed to the failure to implement the discharge process according to facility policy. The discharge paperwork was not prepared, and the interdisciplinary meeting did not occur, leading to the resident being discharged without the necessary support and services in place. The facility acknowledged these deficiencies, but the report does not include any corrective actions taken to address the issue.
Failure to Complete Recapitulation of Stay for Discharged Resident
Penalty
Summary
The facility failed to complete a recapitulation of stay for a resident who was discharged to the community. The resident was admitted with diagnoses including a right femur fracture, peripheral vascular disease, atrial fibrillation, and chronic obstructive pulmonary disease. The resident's cognition was intact as per the Minimum Data Set assessment. Upon discharge, the facility did not complete the necessary recapitulation of stay, which is a summary of the services provided during the resident's stay. Interviews with the Administrator and the Director of Nursing revealed that the discharge summary was not completed due to the absence of a social worker, and there was uncertainty about why the recapitulation was not done.
Inaccurate MDS Coding for Cognitive Patterns and Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of cognitive patterns and medication documentation. Resident #251, who was admitted with diagnoses including malignant neoplasm and tracheostomy status, had an MDS assessment that inaccurately marked the resident as rarely/never understood, without assessing the cognitive patterns section. The MDS nurse acknowledged that the cognition section should have been completed using staff interviews to assess the resident's cognitive status. The Administrator confirmed that it was expected for all MDS assessments to accurately reflect the resident's cognition status. For Resident #38, the MDS assessment inaccurately documented that the resident received an insulin injection during the look-back period, despite no medication orders for insulin being present. The MDS nurse clarified that the resident had received a Tuberculosis (TB) test, and the insulin injection entry was an error. The Administrator reiterated the expectation for MDS assessments to accurately reflect the medications administered to residents.
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What surveyors actually found near you
We read the 123 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Reidsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Penn Nursing Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Unc Rockingham Rehab & Nursing Care Center | 10.5 mi | ★★★★★ | 0 | 0 |
| Eden Rehabilitation And Healthcare Center | 12.4 mi | ★★★★★ | 4 | 1 |
| Jacob's Creek Nursing And Rehabilitation Center | 13.1 mi | ★★★★★ | 2 | 0 |
| Blumenthal Health And Rehabilitation Center | 18.2 mi | ★★★★★ | 33 | 0 |
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