Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Creek Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, CKD, and a UTI received IV Vancomycin ordered every 12 hours with instructions for a trough level to be drawn after the 4th dose for ongoing monitoring. The MAR showed that the 4th and multiple subsequent Vancomycin doses were administered without a documented trough level, while nursing notes indicated the antibiotic was continued and the order for the trough was being clarified. The DON later reported that the trough order had been incorrectly set to start several days later, resulting in doses being given before a level was known. When a stat trough was finally drawn, the Vancomycin level was critically high, and the on-call physician was notified and ordered doses to be held, demonstrating a failure to follow MD orders and facility policy for IV medication monitoring.
A resident with cerebral palsy, depressive and mood disorders, and intellectual disabilities, but intact cognition per BIMS, had her electronic medical record left open and unattended on a medication cart, displaying her room, DOB, allergies, code status, and medications. A respiratory therapist reported she left the record open while quickly administering an inhaler and acknowledged that anyone could view the information. The DON stated records should be locked when staff walk away and that leaving them open is a HIPAA violation, while the administrator noted the EMR has a timeout and can be minimized. The facility’s resident rights policy affirms residents’ rights to privacy and to secure, confidential personal and medical records.
A resident with multiple diagnoses, including dry eye syndrome and dementia, developed new redness and drainage in one eye, leading the MD to order Azithromycin ophthalmic drops twice daily. The MAR reflected the new order, but the comprehensive care plan was not revised to include this change in condition or related interventions. Interviews with the DON, ADON, MDS nurse, and administration confirmed that facility policy and practice require immediate or within-24-hour care plan updates after a status change, yet this did not occur for the resident’s eye condition.
Surveyors found two unlocked medication carts during med pass, one used by a respiratory therapist on one hall and another by an LVN on a different hall. The respiratory therapist reported she forgot to lock the cart while assisting a resident with medications, and the LVN reported she left her cart unlocked when responding to a resident yelling for help. The facility’s policy requires all drugs and biologicals to be stored in locked compartments and that medications be either under direct observation during pass or locked, and leadership acknowledged that unlocked carts create a risk of medication being taken and potential harm to residents.
A resident with severe cognitive impairment was physically abused by a CNA, who slapped her on the cheek and acted aggressively. In a separate incident, another resident with dementia and behavioral disturbances struck the same resident multiple times in the arm. Both incidents were witnessed and confirmed, and the affected resident was dependent on staff for care. The facility's existing care plans and interventions did not prevent these abusive events, and some residents were unaware of their rights or how to report abuse.
The facility failed to immediately report allegations of abuse and significant injuries of unknown origin for two residents, including a resident with severe cognitive impairment who sustained unexplained bruising and a fractured arm, and another resident who was slapped by a CNA. In both cases, required notifications to the administrator and state agency were delayed beyond the mandated two-hour window, with staff interviews revealing confusion about reporting procedures and documentation showing lapses in timely communication.
A resident with cognitive and behavioral challenges was subjected to verbal abuse by a CNA, who responded to the resident's use of a racial slur with racially charged and threatening remarks, intimidation, and inappropriate conduct. The incident, captured on video and witnessed by staff and family, demonstrated a failure to follow the resident's care plan and facility policies prohibiting abuse.
Failure to Monitor Vancomycin Trough Levels Before Continued Dosing
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate monitoring and administration of IV Vancomycin for one resident. The resident was an elderly female with dementia, urinary tract infection, chronic kidney disease, acute kidney failure, and hypertension, who was dependent on staff for ADLs and had moderately impaired cognitive skills. Physician orders dated 12/3/25 directed Vancomycin 1 g IV every 12 hours for 14 days for a UTI, with a Vancomycin trough to be drawn at 6 a.m. after the 4th dose every 7 days for two weeks. The Medication Administration Record showed Vancomycin doses given at 7:00 a.m. and 7:00 p.m. starting on 12/3/25, with the 4th dose administered on 12/5/25 at 7:00 a.m., but there was no documentation that a Vancomycin trough was collected after this 4th dose as ordered. Despite the absence of a documented trough level after the 4th dose, Vancomycin continued to be administered on multiple subsequent shifts. Nursing notes documented that the resident continued on IV Vancomycin with no adverse effects noted and that the IV site was intact and flushing well. A late entry nursing note indicated that an LVN was clarifying the Vancomycin trough order, but the MAR still showed that the LVN had administered a dose on the morning in question. Another nurse later documented that the resident received a dose of Vancomycin on her shift and tolerated it well. The DON later stated that a nurse had entered the Vancomycin trough order to start on 12/7/25 instead of after the 4th dose, and that some Vancomycin doses were given before the trough level was known. On 12/7/25, an RN documented that no Vancomycin level had been obtained despite the resident having received more than four doses, and contacted the lab for a stat trough before the next dose. A Vancomycin trough was collected that afternoon, and the laboratory result showed a critical high level of 33.7 ug/mL (reference range 10.0–20.0), which was called into the facility that night. A nursing note documented that this critical trough level was reported to the on-call physician, who ordered the next two doses of Vancomycin to be held. The resident’s physician later stated that Vancomycin troughs were normally drawn 30 minutes to 1 hour before every 4th dose and that without knowing the initial trough, nursing staff could not continue to give the medication. The facility’s policies on medication administration and IV therapy required medications to be administered as ordered by the physician and in accordance with professional standards of practice, including review and verification of orders for dose and frequency, which did not occur in this case.
Failure to Maintain Confidentiality of Resident Electronic Medical Record
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident’s personal and medical records when the resident’s electronic medical record (EMR) was left open and unattended on a medication cart. The resident was an adult female with cerebral palsy, major depressive disorder, mood disorder due to a known physiological condition, and intellectual disabilities, with an initial admission date in 2022 and a recent readmission. A Quarterly MDS assessment documented a BIMS score of 15, indicating intact cognition with normal memory and recall. Her care plan noted a risk for cognitive impairment related to mild intellectual disorders, with interventions to monitor and report changes in cognitive function. Despite this, during an observation on the 100 hall, her EMR was visible on the cart screen, displaying her room location, date of birth, allergies, code status, and medications. During an interview shortly after the observation, the respiratory therapist who had been administering an inhaler to the resident acknowledged leaving the medical record open and unattended, explaining she was trying to quickly administer medication and did not realize the record remained open. She stated that leaving medical records open allowed anyone to view the documents. The DON stated that medical records should not be left open when staff walk away from the cart and should be locked, noting that wandering eyes could view residents’ information and that this constituted a HIPAA violation. The administrator reported that the EMR has a built-in timeout and that staff can minimize the screen to lock it before walking away, and also noted that in-services on confidentiality are conducted periodically. The facility’s Resident Rights policy, revised in 01/2025, states that residents have the right to personal privacy and to secure and confidential personal and medical records, and the right to refuse release of such records except as allowed by law.
Failure to Revise Care Plan After Resident Eye Condition Change
Penalty
Summary
The facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after a documented change in condition for one resident. The resident was an older male with an initial admission in early April 2023 and a recent readmission, with diagnoses including dry eye syndrome, cerebral infarction, dementia, congestive heart failure, dizziness and giddiness, and chronic cough. An MDS assessment showed a BIMS score of 13 and indicated the resident could see fine detail such as regular print. A change in condition progress note dated 01/27/2026 documented that the resident developed redness to the right eye with a small amount of drainage, and the physician ordered Azithromycin 1% ophthalmic solution, one drop to the right eye twice daily for five days. The Medication Administration Record reflected this new order dated 01/27/2026. Despite this documented change in condition and new treatment order, review of the resident’s care plan showed no indication of a change in condition regarding the eye. Interviews with the DON, Administrator, MDS Specialist (LVN), and ADON confirmed that the facility’s expectation and policy were that care plans be updated immediately or within 24 hours after a status change, typically following SBAR completion and IDT discussion, and that such updates are then communicated to staff via the Kardex. The DON acknowledged that for this resident the care plan was not updated timely and accepted accountability. Staff interviews consistently identified that the care plan should have been revised after the change in condition was identified and the new order was received, but this did not occur for the resident’s right eye redness and drainage.
Unlocked Medication Carts During Med Pass
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security when two medication carts were found unlocked during observations. On the 100 hall, the respiratory therapist’s medication cart was observed unlocked at 7:18 a.m. The respiratory therapist stated in an interview that she had been assisting a resident with medications and forgot to lock the cart, acknowledging that anyone could come and take the medications. The facility’s Medication Storage policy, revised 05/2023, requires that all drugs and biologicals be stored in locked compartments and that, during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area or cart. On the 300 hall, a nurse’s medication cart was observed unlocked at 7:24 a.m. The LVN assigned to that cart stated in an interview that she heard a resident yelling for help and went to assist, leaving the cart unlocked. She stated that the risk of leaving the cart unlocked was that a resident could possibly get into the cart and take medication. In interviews, the DON stated that the expectation is for medication carts to be locked before staff walk away, and the risk of unlocked carts is that medication could be taken out and used for alternative purposes. The administrator stated that, for safety and security, they conduct purposeful rounding to double-check that medication carts are locked when staff walk away and that her role is to ensure systems are completed within local and state compliance and to address deficient practices. The report notes that the risk of medication carts being unlocked is medication error and potential harm to residents.
Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member and another resident. One incident involved a CNA physically abusing a resident with severe cognitive impairment by slapping her on the left cheek with an open hand and pointing at her aggressively. The resident, who had diagnoses including colon cancer, hemiplegia, vascular dementia, and adjustment disorder, was dependent on staff for activities of daily living and had a BIMS score indicating severe cognitive impairment. The abuse was confirmed through video evidence and staff interviews, with the CNA admitting to the act during an interview. The incident was reported by another CNA, and the resident was observed to be yelling and distressed immediately after the event. A second incident involved resident-to-resident abuse, where another resident with severe cognitive impairment and a history of behavioral disturbances struck the same resident three times in the arm with a closed fist. This altercation occurred at the nurse's station and was witnessed by an LVN. The aggressor resident had a history of dementia with behavioral disturbance, diabetes, and other significant medical conditions. The behavior was noted to be outside her baseline, and it was later determined that she had a urinary tract infection and elevated ammonia levels, which may have contributed to the aggression. Both residents were assessed after the incident, and no visible injuries were noted. The facility's care plans for both residents included interventions for managing unwanted behaviors and cognitive impairment, but these interventions did not prevent the incidents of abuse. Staff interviews indicated that some residents were unaware of their rights or how to report abuse prior to the incidents. The events placed residents at risk of abuse and mental anguish caused by fear, as directly observed and documented by surveyors.
Failure to Timely Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, but not later than two hours after the allegation was made, to the administrator and to other officials, including the State Survey Agency, as required by state law. This deficiency was identified for two residents reviewed for abuse and neglect. In one case, a resident with severe cognitive impairment and multiple comorbidities, including dementia and diabetes, was found to have scattered bruising of different colors and a fractured arm. The injury was not reported to the state agency or the abuse coordinator in a timely manner, despite the presence of significant bruising and a fracture of unknown origin. Staff interviews revealed confusion about the timing and reporting of the injury, with some staff believing the injury was older than it appeared and others unsure of who had been notified. Documentation showed that the injury was not immediately recognized or reported, and the cause of the injury remained unclear. In another instance, an allegation of abuse involving a staff member slapping a resident on the cheek was not reported to the administrator or the state agency within the required two-hour timeframe. The incident was reported 15 hours after it occurred. Staff interviews indicated a lack of clarity regarding the appropriate method and urgency of reporting such incidents, with some staff relying on text messages rather than direct phone calls to notify management. The facility's own policy required immediate reporting of suspected abuse, neglect, or injury of unknown origin, but this was not followed in practice. Both failures were substantiated by record reviews, staff interviews, and review of facility policies. The lack of timely reporting of these incidents could place residents at risk for abuse or neglect and could lead to a diminished quality of life, as stated in the report. The findings highlight lapses in communication, documentation, and adherence to established procedures for reporting suspected abuse and significant injuries.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) engaged in verbally abusive behavior toward a male resident with a history of psychotic and mood disturbances, anxiety, dementia, and other medical conditions. The incident began when the resident, who was cognitively intact according to his most recent assessment, used a racial slur toward the CNA. In response, the CNA pointed her finger close to the resident's face, made racially charged and derogatory remarks, threatened to remove the resident's refrigerator, and turned off the lights in the resident's room, telling him to "stay in the dark." The interaction was captured on a camera in the resident's room, and the resident's family was alerted to the commotion via a motion notification from the camera. The resident's care plan documented his communication difficulties, occasional resistance to care, and a history of unwanted behaviors, including aggression and use of inappropriate language. Despite these challenges, the care plan included interventions such as using simple language, allowing time for responses, and providing choices during care. On the day of the incident, the CNA did not follow these interventions and instead escalated the situation by responding to the resident's verbal aggression with her own verbal abuse and intimidation. The incident was witnessed by another CNA, who confirmed the resident's use of a racial slur but did not recall threatening or disrespectful language from the CNA involved, although video evidence and interviews contradicted this account. Following the incident, the resident was assessed and found to have no physical injuries or signs of emotional distress, and he later reported that while the CNA's behavior did not make him sad or angry, he did not feel good about the interaction. The CNA involved refused to provide a statement and left the facility, effectively self-terminating her employment. The facility's policies on resident rights and abuse prohibit such behavior, defining verbal abuse as the use of disparaging or derogatory terms within a resident's hearing, regardless of their ability to comprehend. The actions of the CNA were found to be in violation of these policies, constituting a failure to protect the resident from abuse.
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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 Cypress
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eagle Crest Rapid Recovery | 2.5 mi | ★★★★★ | 26 | 3 |
| Fallbrook Rehabilitation And Care Center | 3.3 mi | ★★★★★ | 17 | 4 |
| Park Manor Of Cyfair | 3.3 mi | ★★★★★ | 1 | 0 |
| Cypress Pointe Health & Wellness | 3.5 mi | ★★★★★ | 12 | 0 |
| North Houston Transitional Care | 4 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.