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 The Cypress At Midtown during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors found multiple unlabeled, undated, and/or unsealed food items in the Atosa 2-door reach-in fridge and Advantco freezer, including expired chocolate milk and an opened package of turkey breast. They also observed lint, food debris, and food splatters in refrigerator and freezer vents, food debris on the oven top and fridge interior, and uncovered plates, bowls, and thermal plate containers stored with food-contact surfaces facing up. The Cook-D and CDM confirmed the observations.
Failure to Complete GDR and Psychotropic Monitoring: A resident with anxiety, depression, and insomnia received duloxetine, trazodone, and buspirone, but the facility did not complete the required GDR for duloxetine in the required timeframe. The record also showed no documented monitoring of behaviors, side effects, or non-pharmacological interventions for duloxetine and trazodone, and the DON confirmed that psychotropic monitoring was only documented for buspirone.
Medication administration errors exceeded the allowed rate, with 2 errors found in 26 observed medications. An LPN administered two insulin pens to a resident with diabetes without priming either pen first, and the DON confirmed the pens should have been primed before dose selection and that this was a medication error.
Failure to Prime Insulin Pens Before Administration: An LPN administered two insulin pens to a resident without priming either pen first. The resident had orders for rapid-acting insulin before meals and long-acting insulin twice daily. The LPN confirmed the pens were not primed, and the DON stated the pens should have been primed before dose selection and that this was a medication error.
Failure to use required PPE during wound care: A resident on EBP for multiple wounds had wound care performed while a hospice RN was in the room without a gown. The RN touched the resident’s wounds and lifted the resident’s lower extremity several times while an LPN applied dressings, despite posted EBP guidance requiring gloves and a gown for high-contact care such as wound care.
Surveyors found that staff failed to follow the facility’s infection prevention and hand hygiene policies during wound care for two residents with complex wounds. An LPN repeatedly changed gloves without performing hand hygiene while cleansing and dressing a Stage 4 pressure ulcer and a toe wound, and cleaned the wounds by moving back and forth between intact skin and the wound bed. A nurse aide also used a gloved hand that had been in contact with a resident’s skin to stabilize wound dressings. Both staff later acknowledged these practices created opportunities for cross contamination.
Two residents with cognitive impairment and a history of falls did not receive care-planned fall prevention interventions, including required alarms and fall mats, as confirmed by observations and staff interviews.
The facility failed to provide baths according to the care plans for two residents. One resident with severe cognitive impairment received baths with a 10-day gap, despite a weekly bath preference. Another cognitively intact resident also experienced a 10-day gap, contrary to their preference for two weekly baths. The DON acknowledged these intervals were too long, and the facility's policy on maintaining hygiene was not followed.
The facility failed to adhere to practitioner's orders for wound care for two residents. A resident had compression dressings applied in the wrong order, contrary to the prescribed method. Another resident's sacral wound dressing was not changed daily as ordered, with the dressing observed to be two days old. These deficiencies were confirmed through staff interviews and observations.
A resident with severe cognitive impairment and identified as a fall risk was left unsupervised in their room, contrary to the care plan's directive for supervision while in a chair. Facility staff misunderstood the supervision requirements, believing it was only necessary during meals, leading to a failure in implementing fall prevention interventions.
A resident with severe cognitive impairment and swallowing difficulties was not provided with the necessary assistive eating equipment as outlined in their care plan. Despite requiring a scoop plate, weighted utensils, and two-handled cups, observations revealed the resident was served meals without these aids, using a one-handled cup and regular glass instead. Staff interviews confirmed the oversight, indicating a failure to adhere to the resident's care plan.
A facility failed to ensure proper hand hygiene during incontinent care for a resident. An NA did not change gloves or sanitize hands after removing a soiled brief and before cleansing the resident, nor did they dry the cleansed areas. The DON confirmed the NA did not meet the facility's hand hygiene expectations.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food stored in the kitchen was labeled, dated, and/or sealed, and failed to keep refrigerators and freezers free of expired products. During observation of the Atosa 2-door reach-in fridge, surveyors found a pack of a white substance not labeled, a large Zip Lock style bag containing a white substance not sealed or labeled, a pack of yellow slices wrapped in plastic wrap not labeled or dated, a large Zip Lock style bag containing an opened package labeled turkey breast that was not dated, a steam pan containing a plastic and aluminum foil wrapped substance not labeled or dated, a bag of brown slices not labeled, two half-pint containers of 1% chocolate milk with a use-by date of 04/20/2026, a gallon jug of 2% chocolate milk with an expiration date of 04/26/2026, and three bags of green items not labeled or dated. The Advantco 2-door reach-in freezer contained an open Zip Lock style bag with a brown substance that was not labeled. The Cook-D confirmed the items were not labeled, dated, or sealed as required, and the CDM later confirmed the same observations. The facility also failed to maintain kitchen equipment and food service items in a clean and sanitary manner. Surveyors observed lint, food debris, and food splatters in the bottom vents of the Atosa 2-door reach-in fridge and the Advantco 2-door reach-in freezer, and food debris and splatters in the interior bottom and bottom vent of the True single-door reach-in fridge. The top of the Sunfire double-door oven had food debris. In addition, small plates, bowls, and thermal plate containers stored on shelves by the dish machine were placed upright with the food contact surfaces facing up and uncovered. The Cook-D and the CDM both confirmed these conditions during interview.
Failure to Complete GDR and Psychotropic Monitoring
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was completed in the required timeframe for a resident receiving duloxetine, and it also failed to monitor for behaviors and adverse consequences and document non-pharmacological interventions related to duloxetine and trazodone. The resident had diagnoses of Adjustment Disorder With Mixed Anxiety and Depression and Insomnia, and the MDS showed a BIMS score of 15, indicating the resident was cognitively aware. The care plan identified behavioral concerns, use of psychotropic medications for mood disorder with anxiety and depression, and the need to monitor and document target behaviors, mood, nursing staff problems, and adverse reactions. The resident had orders for duloxetine 60 mg daily, with the medication originally started at 20 mg and later increased to 30 mg and then 60 mg. The facility pharmacy record showed duloxetine had been increased for pain and that the last GDR had been completed previously, while a consultant recommendation stated that a trial dose reduction may be reasonable. However, neither physician responded to or signed the consultant recommendation, and the consultant pharmacist MRR also noted that GDR was required twice in the first year of therapy and annually thereafter unless clinically contraindicated. The Administrator confirmed the facility did not have a GDR for the resident's duloxetine. The resident also had orders for trazodone at bedtime and buspirone twice daily, but the only psychotropic monitoring documented on the Order Summary Report and MAR/TAR was for buspirone. The EMR did not show behavior monitoring in the tasks, and it did not show behaviors, side effects, or non-pharmacological interventions completed on paper and scanned into the record. The DON confirmed that the only medication monitoring for behaviors, side effects, and interventions was for buspirone on the MAR/TAR.
Medication Error Rate Exceeded During Insulin Administration
Penalty
Summary
Medication administration errors exceeded the facility’s allowed rate of less than 5%, with 2 errors identified during observation of 26 medications for a rate of 7.69%. The errors were related to 1 of 4 sampled residents, and the facility census was 49. Review of the facility’s medication administration policy stated that the six rights of medication administration must be followed, including the right resident, drug, dosage, route, time, and documentation. For a resident with type 2 diabetes mellitus with hyperglycemia and type 2 diabetes mellitus with chronic kidney disease, the treatment administration record showed orders for Fiasp FlexTouch 100 unit/milliliter, 8 units subcutaneously before meals, and Insulin Glargine Solostar 100 unit/milliliter, 75 units subcutaneously two times a day, with instructions to hold if blood sugar was less than 100 and call the doctor for blood sugars less than 100 or greater than 450. During observation of insulin administration, an LPN obtained the resident’s blood sugar of 143, prepared both insulin pens, and administered each insulin without priming the pens first. The LPN confirmed the pens were not primed, and the DON confirmed the insulin pens should have been primed before the dose was selected and that this would be considered a medication error.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when staff did not prime insulin pens before administering insulin. The facility policy titled "Insulin Pen Policy" stated that insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir, and the procedure required dialing 2 units and confirming at least one drop of insulin appeared on the needle tip before use. Record review for Resident 8 showed orders for Fiasp FlexTouch 100 unit/mL, 8 units subcutaneously before meals for type 2 diabetes mellitus with hyperglycemia, and Insulin Glargine Solostar 100 unit/mL, 75 units subcutaneously twice daily for type 2 diabetes mellitus with chronic kidney disease, with instructions to hold if blood sugar was less than 100 and call the physician for blood sugars less than 100 or greater than 450. During observation of medication administration, an LPN checked the resident's blood sugar at 143, prepared the Insulin Glargine pen, attached the needle, selected 75 units, and injected it into the resident's lower abdomen without priming the pen. The LPN then prepared the Fiasp pen, selected 8 units, and also injected it without priming. The LPN confirmed the pens were not primed, and the DON confirmed the pens should have been primed before selecting the dose and that this was a medication error.
Failure to Use Required PPE During Wound Care
Penalty
Summary
The facility failed to ensure hospice staff donned personal protective equipment during wound care in a manner to prevent cross contamination for one resident. The facility’s Enhanced Barrier Precautions policy stated that EBP is an infection control intervention that uses targeted gown and glove use during high-contact care such as wound care, and the EBP sign posted at the resident’s room stated that providers and staff must wear gloves and a gown for high-contact resident care activities such as wound care. Resident 45 had orders for wound care to the left inner heel, an open area above the left heel, a skin tear to the left shin, and scabs on the left shin, and was placed on EBP due to wounds with instructions to ensure appropriate PPE was used during resident care activities. During observation, the hospice RN was in the room after removing the ankle dressing and did not have a gown on while the LPN completed wound care to the resident’s left lower extremity. The hospice RN touched the resident’s left lower extremity wounds twice and lifted the left lower extremity five times without a gown on while the LPN applied dressings. In interview, the hospice RN confirmed the gown was not worn during the wound care and stated it should have been worn.
Failure to Perform Hand Hygiene and Maintain Aseptic Technique During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff performed appropriate hand hygiene and aseptic technique during wound care, contrary to its Infection Prevention and Control Program and Hand Hygiene policies. The facility’s policies required all staff to follow standard precautions, assume all residents could be infected or colonized, and perform hand hygiene before and after handling clean or soiled dressings, after handling contaminated objects, when moving from contaminated to clean body sites, and before and after glove use. The policies also specified that glove use does not replace hand hygiene and that staff must perform hand hygiene prior to donning gloves and immediately after removing them. For Resident 2, who had multiple serious medical conditions including sepsis, acute kidney failure, and a Stage 4 pressure ulcer with specific wound care orders, an LPN and a nurse aide did not follow proper hand hygiene and aseptic technique during a wound dressing change. After initially washing their hands and donning gowns and gloves, the LPN repeatedly removed and changed gloves multiple times without using hand sanitizer or performing hand hygiene in between glove changes. The LPN cleaned the wound by moving from the peri-wound area to the wound bed and back, including using the same gauze pad to clean both the peri-wound skin and the open wound bed, and then repeated this process with additional gauze pads without hand hygiene between glove changes. The LPN also handled wound care supplies and packed the wound with moistened kerlix while continuing to change gloves without performing hand hygiene. During the same wound care procedure for Resident 2, the nurse aide, who was stabilizing the resident by holding the hip and shoulder, used a gloved hand that had been in contact with the resident’s skin to hold the gauze pad in place while the LPN applied the bordered dressing. This action moved from a dirty area to direct contact with the wound dressing. Both the LPN and the nurse aide later acknowledged that these actions created opportunities for cross contamination and that the nurse aide should not have touched the gauze pad used for the wound dressing with a gloved hand that had been on the resident’s skin. For Resident 3, who had multiple chronic conditions including type 2 diabetes with nephropathy and a wound on the left great toe with specific orders for cleansing and application of Medi honey and alginate, the same LPN again failed to perform hand hygiene between glove changes during wound care. After washing hands and donning gloves and a gown, the LPN removed the old dressing, changed gloves without hand hygiene, and cleaned the wound using gauze pads moistened with wound wash while moving back and forth from the edges of the wound to the center and then back to intact skin. The LPN continued to change gloves multiple times—before applying skin prep, Medi honey, and silver alginate, and before placing the bordered dressing—without performing hand hygiene between glove changes. The LPN later confirmed not using hand hygiene between glove changes and recognized that cleaning from the outside edge of the wound to the wound center and back created an opportunity for cross contamination.
Failure to Implement Fall Prevention Interventions for Two Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in its Fall Prevention Program policy for two of three sampled residents. For one resident with severe cognitive impairment, a history of stroke, and seizures, the care plan required the use of an alarm on both the bed and wheelchair. However, observations on multiple occasions found the resident in a wheelchair without the required alarm, and the Director of Nursing confirmed the alarm was not in use as specified in the care plan. Another resident, assessed as having moderate cognitive impairment and a history of falls, was care planned to have a clip alarm when in bed and chair, as well as a fall mat when in bed. Observations revealed the resident in a wheelchair and in bed without the required clip alarm or fall mat. A nurse aide confirmed these interventions were not in use, and the Director of Nursing acknowledged that the resident should have had both the clip alarm and fall mat in place according to the care plan.
Failure to Provide Scheduled Baths for Residents
Penalty
Summary
The facility failed to provide baths according to the plan of care for two residents, Resident 17 and Resident 34, out of a sample of three residents. Resident 17, who has a severe cognitive impairment with a BIMS score of 0, required extensive assistance with activities such as toileting, bathing, transfers, and lower body dressing. The care plan for Resident 17 indicated a preference for a weekly bath on Wednesdays. However, the electronic health record showed that baths were provided on December 4 and December 14, 2024, resulting in a 10-day gap between baths. The Director of Nursing acknowledged that this interval was too long. Similarly, Resident 34, who is cognitively intact with a BIMS score of 14, required substantial assistance with bathing and lower body dressing, and total assistance with transfers and toileting. Resident 34's bathing preferences document indicated a desire for two baths per week. However, the electronic health record revealed that baths were given on December 5 and December 15, 2024, also resulting in a 10-day gap. The facility's policy on resident showers emphasizes maintaining proper hygiene and providing showers as per request or facility schedule, but this was not adhered to in these cases.
Failure to Follow Wound Care Orders for Two Residents
Penalty
Summary
The facility failed to follow practitioner's orders for wound care and skin integrity for two residents. Resident 5, who was cognitively intact and required assistance with various activities of daily living, had an order for a double layer of compression to both lower extremities. The correct procedure was to apply edema wear first, followed by tubigrip. However, observations revealed that the dressings were applied in the reverse order, which was confirmed by RN B during an interview. Resident 34, also cognitively intact and requiring assistance with daily activities, had an order for daily wound care to a sacral wound. The treatment involved applying a Vashe compress followed by triad paste, with a daily dressing change. An observation showed that the dressing on Resident 34's sacrum was dated two days prior and had not been changed as required. RN E confirmed that the dressing should have been changed daily, according to the order and facility policy.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent potential falls for Resident 17, who was identified as a fall risk. The resident, with a severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 0, required substantial assistance with various activities of daily living, including toileting, showering, lower body dressing, and transfers. Despite a care plan intervention initiated on December 18, 2024, which required staff to supervise the resident while they were up in a chair in their room, observations on January 2 and January 6, 2025, revealed that the resident was left unsupervised in their room. Interviews with facility staff, including a Nursing Assistant, Medication Aid, and Licensed Practical Nurse, indicated a misunderstanding or lack of awareness regarding the supervision requirements for Resident 17. The staff believed supervision was only necessary during meals, contrary to the care plan's directive. The Director of Nursing confirmed the intervention for the resident's fall risk was to have staff supervise the resident while they were in a chair in their room, highlighting a failure in communication and implementation of the care plan designed to mitigate fall risks.
Failure to Provide Assistive Eating Equipment
Penalty
Summary
The facility failed to provide the necessary assistive equipment for eating to a resident, identified as Resident 17, who was assessed to have severe cognitive impairment and required assistance with various activities, including eating. The resident's care plan, revised in September 2024, indicated a risk for nutritional problems due to a history of stroke and swallowing difficulties. The care plan specified the use of a scoop plate, weighted utensils, and two-handled cups during meals to aid the resident. However, observations on multiple occasions revealed that the resident was not provided with the prescribed assistive equipment, such as a scoop plate and two-handled cups, during meals. On December 31, 2024, and January 2, 2025, the resident was observed using a maroon one-handled cup without a lid and a regular glass for juice, contrary to the care plan instructions. Further observations on January 6, 2025, confirmed the absence of a scoop plate and two-handled cups during breakfast. Interviews with Nursing Assistant E and the Dietary Manager corroborated these findings, acknowledging the failure to provide the necessary adaptive equipment as outlined in the resident's care plan. This deficiency highlights the facility's failure to adhere to the care plan designed to address the resident's specific needs for safe and effective eating assistance.
Failure to Perform Proper Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to ensure that staff performed proper hand hygiene during the provision of incontinent care for a resident. During an observation, a nursing assistant (NA-A) was seen not performing hand hygiene or changing gloves after removing a soiled brief and before cleansing the resident's genital area. The NA-A also did not dry the cleansed areas and continued to perform tasks without changing gloves or sanitizing hands. The Director of Nursing (DON) confirmed that the NA-A did not meet the facility's expectations for hand hygiene and acknowledged the need for frequent hand washing and glove changes during care. The facility's policies on perineal care and hand hygiene were reviewed and indicated that hand hygiene should be performed before and after glove use, and that areas should be dried after cleansing. Despite these policies, the observed practices did not align with the guidelines, leading to a deficiency in infection prevention and control. The DON mentioned that the facility had discussed providing small bottles of sanitizer for staff to carry, but this had not yet been implemented.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Douglas County Health Center | 0.4 mi | ★★★★★ | 2 | 0 |
| Emerald Nursing & Rehab Omaha | 2.1 mi | ★★★★★ | 31 | 0 |
| Ambassador Health Of Omaha | 2.3 mi | ★★★★★ | 0 | 0 |
| St. Joseph Villa Nursing Center | 2.5 mi | ★★★★★ | 27 | 0 |
| Omaha Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 3 | 0 |
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