Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cypress Grove Post Acute during CMS and state inspections, most recent first.
A resident with COPD, muscle weakness, and HTN was observed receiving oxygen by nasal cannula at 3 L while the DON confirmed the physician order was for 2 L. Facility policy and the Treat in Place Protocol required oxygen to be given according to the order, but the resident’s oxygen was not administered at the prescribed rate.
An LPN used a pulse oximeter and wrist BP monitor on a resident with severe cognitive impairment, then placed the uncleaned equipment on and inside the med cart without disinfecting it or the cart surface. In a separate event, an RN performing blood glucose testing on another resident with severe cognitive impairment discarded a used lancet in the resident’s trash can instead of a sharps container. The DON confirmed the equipment should have been cleaned and the lancet should have gone into the sharps container.
Four disposable razors were found unsecured in a bathroom used by a severely cognitively impaired resident on a secured unit with multiple wandering residents. Facility policy requires immediate disposal of sharps in designated containers, but this was not followed. Staff and the DON confirmed that razors should not be left out in the open.
Staff failed to secure and lock medication carts, leaving medications unattended and accessible. An LPN left a medication cart unlocked while attending to a resident, and an RN left medications unattended on a cart after walking away. Both staff and the DON confirmed that medications should not be left unsecured.
Two residents were exposed to unsafe infection control practices during medication administration when an LPN used a syringe that had been dropped on the floor and an RN failed to disinfect a stethoscope between uses. These actions were not consistent with facility policies requiring proper cleaning and disinfection of reusable equipment.
A resident with multiple health issues developed a pressure ulcer on the right foot, which was not promptly treated or reported to medical professionals by the LTC facility. The wound worsened, leading to hospitalization and amputation. Interviews revealed a lack of communication and awareness among staff regarding the resident's condition.
The facility failed to maintain a clean and sanitary environment in three hallways, with observations revealing wet and discolored ceiling tiles, potentially indicating mold or mildew. The Administrator acknowledged condensation issues but was unaware of mold problems, while the Maintenance Supervisor confirmed the need for good repair.
Oxygen Was Administered Above the Ordered Flow Rate
Penalty
Summary
The facility failed to follow physician orders for oxygen administration for a resident with chronic obstructive pulmonary disease, muscle weakness, and hypertension. The resident’s record showed she was cognitively intact and received oxygen therapy and respiratory therapy. Facility policy required oxygen to be administered according to physician orders, and the Treat in Place Protocol directed supplemental oxygen at 2 L per nasal cannula for dyspnea when oxygen saturation was 92% or less or there was a decline in respiratory status. Observations in the resident’s room showed her in bed wearing a nasal cannula with oxygen running at 3 L, including during a later observation when she was asleep. During an interview, the DON verified the oxygen concentrator was set at 3 liters and stated the resident’s oxygen was ordered at 2 liters. The facility failed to ensure the resident’s oxygen was administered at the ordered 2 L by nasal cannula.
Infection Control Lapses With Reusable Equipment and Sharps Disposal
Penalty
Summary
The facility failed to ensure infection prevention and control when reusable resident-care equipment was not cleaned after use and when a used lancet was not disposed of in a sharps container. Facility policy required reusable resident-care items and equipment to be cleaned and disinfected between residents, and contaminated sharps to be discarded into designated puncture-resistant, leakproof sharps containers. Resident #42 had diagnoses including diabetes mellitus, hypertension, and vascular dementia, and his BIMS score indicated severe cognitive impairment. During medication administration, an LPN used a pulse oximeter and an automatic wrist blood pressure monitor to obtain the resident’s heart rate and blood pressure, then placed both items on top of the medication cart and later into the top drawer without cleaning them or placing them on a barrier. The LPN also did not clean the top of the medication cart after the items were removed. When asked, the LPN acknowledged the equipment should have been cleaned before being placed in the cart. Resident #104 had diagnoses including diabetes mellitus and chronic kidney disease, and his BIMS score indicated severe cognitive impairment. During blood glucose testing, an RN cleaned the resident’s finger, used a lancet to obtain the specimen, and then placed the used lancet inside her glove and discarded it in the resident’s trash can. The RN stated the lancet was in the glove she threw away, and later confirmed that a used lancet should be placed in the sharps container. The DON stated that disposing of a used lancet in a resident’s trash can was not acceptable and could create an opportunity for the spread of infection.
Unsecured Sharps Found in Resident Bathroom on Secured Unit
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards when four disposable razors were found unsecured on top of the paper towel dispenser in a resident's bathroom on the secured unit. This was observed during two separate times on the same day. The facility's policy requires that contaminated sharps be discarded immediately into designated, closable, and puncture-resistant containers, which was not followed in this instance. The resident involved had diagnoses including dementia, anxiety, heart failure, and depression, and was assessed as severely cognitively impaired with a BIMS score of 6. The resident required extensive assistance with activities of daily living and resided on a secured unit with ten wandering residents. Staff interviews confirmed the presence of the razors, and the Director of Nursing acknowledged that razors should not be left out in the open in the secure unit.
Failure to Secure and Lock Medication Carts
Penalty
Summary
The facility failed to ensure that medications were properly stored and secured, as required by policy and professional standards. On two separate occasions, staff members left medication carts unlocked and unattended. Specifically, an LPN entered a resident's room and left the Memory Care medication cart unlocked and unattended, while an RN gathered medications and supplies at the 300 Hall medication cart, then walked away, leaving a resident's medications unattended and out of sight. Both staff members acknowledged that medications should not have been left unsecured, and the Director of Nursing confirmed that medication carts and medications should not be left unlocked or unattended.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to ensure safe infection control practices during medication administration for two residents. In one instance, an LPN dropped a syringe on the floor while preparing to administer medication to a resident with chronic kidney disease and diabetes, then picked up the contaminated syringe and proceeded to use it to administer the medication. The resident was cognitively intact at the time of the incident. The Director of Nursing later confirmed that staff should have disposed of the contaminated syringe and used a new one. In another instance, an RN used a stethoscope on a resident with dementia, a gastrostomy tube, dysphagia, and anxiety to administer medication via PEG tube, but failed to disinfect the stethoscope after use. The Infection Control Preventionist confirmed that reusable equipment, such as stethoscopes, should be cleaned with germicidal wipes after each use. These actions were not in accordance with the facility's infection prevention and control policies, which require proper cleaning and disinfection of reusable items between residents.
Failure to Provide Timely Wound Care Leads to Amputation
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a pressure ulcer on the right foot, leading to significant harm. The resident, who was admitted with multiple diagnoses including paraplegia and end-stage renal disease, developed a new wound on the right foot. Despite the resident's cognitive intactness and dependency on staff for care, the facility did not promptly notify the physician or initiate wound care treatment. The wound, initially identified as a vascular arterial ulcer, was not treated for three days, and the physician was not informed of its presence or deterioration. The wound worsened over time, with increased drainage and a foul odor, yet the facility failed to notify the physician or the Family Nurse Practitioner (FNP) of these changes. The facility also did not document daily attempts to secure an earlier appointment at the wound care clinic, as instructed. The resident's condition deteriorated to the point where the wound was classified as a Stage IV pressure ulcer with necrotic tissue, leading to an emergency room visit and subsequent hospitalization for osteomyelitis, resulting in the amputation of the fifth metatarsal. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed a lack of awareness and communication regarding the resident's declining condition. The DON admitted to not being informed of the wound's deterioration until the day of the wound care appointment, while the Administrator acknowledged that the provider should have been notified immediately upon the wound's identification. The facility's failure to act promptly and communicate effectively with medical professionals contributed to the resident's harm.
Facility Fails to Maintain Sanitary Environment in Hallways
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in three of its hallways, specifically the 100-Hall, 200-Hall, and 300-Hall. Observations made on September 18, 2024, revealed issues with ceiling tiles in these areas. On the 100 Hall, a ceiling tile near the nurse's station appeared wet with brown areas. On the 200 Hall, four ceiling tiles at the end of the hallway had black areas. Similarly, on the 300 Hall, a ceiling tile past the nurse's station also had black areas. During an interview, the Administrator acknowledged the possibility of mold or mildew due to condensation but was unaware of any mold problems. The Maintenance Supervisor confirmed that the facility should be kept in good repair.
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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 Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Tennessee Post Acute | 0.1 mi | ★★★★★ | 4 | 0 |
| Mission Convalescent Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Laurelwood Health Care Center | 2.7 mi | ★★★★★ | 5 | 1 |
| Maplewood Health Care Center | 3.2 mi | ★★★★★ | 3 | 0 |
| Northbrooke Post Acute | 3.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.