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 Park Manor Of Cypress Station during CMS and state inspections, most recent first.
A resident with a history of physical aggression and moderate cognitive impairment, care planned for potential combative behavior and rummaging in others’ rooms, was seated on an outdoor patio across from another resident with quadriplegia, epilepsy, and verbally abusive behaviors but intact cognition. After the second resident spoke a phrase to activate his phone headset, the first resident stood up from his wheelchair, walked across the patio, and delivered a forceful punch to the second resident’s face, as witnessed by the Activity Director. The assaulted resident, who had limited arm and hand mobility and could not defend himself, reported excruciating facial pain and was later evaluated at a hospital for an alleged assault and facial bruise. This occurred despite existing care plans and an abuse prevention policy intended to identify and address patterns of potential mistreatment and protect residents from abuse.
The facility failed to implement its abuse prevention policies when a resident with a history of physical aggression and moderate cognitive impairment left his wheelchair, crossed a patio, and punched another resident with quadriplegia in the face while the second resident was using his phone. The assaulted resident, who had no cognitive impairment but was physically dependent with limited arm and hand mobility, reported facial pain and was later evaluated at a hospital for an alleged assault and facial bruise. Despite documented prior aggressive incidents and care plans addressing physical behaviors and rummaging, the aggressive resident was later readmitted and moved to a room four doors down and across the hall from the assaulted resident at the end of a dead-end hallway. The assaulted resident stated staff did not consult him about this move and that the aggressive resident now sat outside his room and looked in, illustrating the facility’s failure to use its written policies and procedures to prevent further abuse and to avoid placing the two residents in close proximity after a known assault.
A resident with cognitive impairment, bipolar disorder, and a history of physical aggression had a care plan identifying potential for physical behaviors and calling for analysis of circumstances, triggers, and de-escalating factors after incidents. Despite this, the resident physically struck two other residents on separate occasions, once in a hallway after an argument over a preferred seating spot and once on a patio after apparently misinterpreting another resident’s phone use. Investigation reports for both events did not document any analysis of circumstances or triggers, and interviews with CNAs, the DON, the Social Worker, and the Administrator showed staff were either unaware of specific triggers or had not assessed them, even though some knew of the resident’s history of physical abuse. This reflects a failure to implement the resident’s behavior-specific care plan and to ensure staff understood the resident’s behavioral triggers.
Two residents did not receive their medications as ordered, with one experiencing significant delays in receiving multiple prescribed drugs and another nearly receiving an incorrect dose of Lisinopril until a nurse surveyor intervened. Staff interviews and record reviews indicated inconsistent adherence to medication administration procedures, despite facility policies requiring timely and accurate delivery of pharmaceuticals.
The facility failed to maintain cleanliness in the kitchen, as two divided plates with black and metallic substances were found under the steam table. The Dietary Manager acknowledged the issue, and the plates were removed for re-washing and sanitization. The Administrator emphasized the importance of cleanliness and stated that the dietary department would be moving in-house in the summer of 2024.
A facility failed to properly dispose of Rivastigmine patches for a resident, leading to patches being found on the floor. Staff had inconsistent understandings of proper disposal procedures, with some stating patches should be placed in a sharps container and others saying they should be thrown in the trash.
A resident was nearly administered the incorrect dosage of Eliquis by a medication aide, who attempted to give 5 mg instead of the prescribed 2.5 mg. The surveyor intervened, and the DON confirmed the importance of following physician orders accurately.
A resident with severe cognitive impairment and multiple medical conditions was found to have a non-functional call light. Despite daily checks by staff, the issue was not identified until observed by surveyors. The facility's policy on ensuring functional call lights was not effectively implemented.
A resident with Alzheimer's and other conditions was found with a roach and ants in her bed, indicating the facility's failure to maintain an effective pest control program. The DON and Administrator acknowledged the issue, and emergency pest control treatment was conducted.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse when another resident physically assaulted him. One resident (Resident #2), who had encephalopathy, aphasia, hemiplegia/hemiparesis following a cerebral infarction, bipolar disorder, and anxiety disorder, had a documented history and care plan for potential physical behaviors, including alleged physical aggression toward other residents on three prior dates. His care plan included interventions such as psychiatric consultation, analysis of triggers, providing cues to alleviate anxiety, offering choices, and intervening as necessary to protect the rights and safety of others. Despite these identified risks and interventions, Resident #2 remained in common areas with other residents. On the day of the incident, Resident #2 and another resident (Resident #1) were seated on opposite sides of the outdoor patio. Resident #1, who had quadriplegia, epilepsy, bipolar disorder, and major depressive disorder, had no cognitive impairment per his MDS and was care planned for verbally abusive behaviors such as yelling and cursing at staff and his roommate. While seated outside, Resident #1 activated a task on his phone using a spoken phrase into his headset. According to Resident #1 and the Activity Director, Resident #2 appeared to believe Resident #1 was speaking to him. The Activity Director reported that after hearing Resident #1 activate his phone, Resident #2 suddenly stood up from his wheelchair, walked across the patio, and began swinging at Resident #1, delivering what she described as a “pretty exaggerated punch” to Resident #1’s face. Resident #1 stated that Resident #2 walked a distance across the patio and started swinging at him, causing excruciating pain, and that he felt helpless due to his limited arm and hand mobility. A progress note documented that Resident #2 “suddenly with his fist, hit the other resident on the face,” and Resident #1’s assessment noted facial pain to touch. Hospital documentation showed Resident #1 was evaluated for an alleged assault and discharged with instructions for a facial bruise. The facility’s abuse prevention policy stated residents have the right to be free from abuse and that the program includes identification of occurrences and patterns of potential mistreatment and implementation of changes to prevent future occurrences, but the incident occurred despite Resident #2’s known behavioral history and care-planned risks.
Failure to Implement Abuse Prevention Policies for Resident-to-Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse prevention policies and procedures for two residents with known behavioral and vulnerability issues. The facility had an Abuse Prevention Program policy dated August 2006 stating residents have the right to be free from abuse and that comprehensive policies and procedures were developed to prevent abuse, neglect, or mistreatment, including identification of occurrences and patterns of potential mistreatment/abuse and implementation of changes to prevent future occurrences. Despite this, the facility did not effectively apply these policies when one resident with a history of physical aggression assaulted another resident and when the same two residents were later placed in close proximity to each other. One resident (Resident #2) had multiple neurological and psychiatric diagnoses, including encephalopathy, aphasia, hemiplegia/hemiparesis following cerebral infarction, bipolar disorder, and anxiety disorder. His quarterly MDS showed moderate cognitive impairment (BIMS 9), use of a wheelchair with some independent mobility, and behavioral symptoms. His care plan documented a potential to demonstrate physical behaviors related to agitation and combativeness, with prior alleged physical aggression toward other residents on 12/16/24, 8/8/25, and 9/26/25, and a separate behavior problem of rummaging through other residents’ rooms. On 9/26/25, a progress note documented that he suddenly got out of his wheelchair, walked up to another resident (Resident #1), and hit him in the face with a closed fist, stating he did so because the other resident was “always messing with” him. He was subsequently transferred to the local county jail and later readmitted to the facility. The other resident (Resident #1) had quadriplegia, epilepsy, bipolar disorder, and major depressive disorder, with no cognitive impairment (BIMS 15) but documented verbally abusive behaviors such as yelling and cursing at staff and his roommate on most days. He was dependent on staff for personal hygiene and transfers, used a motorized wheelchair independently, and had limited mobility in his arms and hands. On the day of the physical altercation, he was sitting on the patio using his phone when Resident #2, seated on the other side of the patio, stood up, walked across the patio, and began swinging at him, causing facial pain. A head-to-toe assessment noted pain to the left side of his face, and hospital records documented he was seen for an alleged assault with discharge instructions for a facial bruise. Later, after Resident #2 was readmitted, the facility moved Resident #2 to a new room four doors down and across the hall from Resident #1 at the end of a dead-end hallway. Resident #1 reported that staff did not speak to him when Resident #2 was moved to his hallway, that Resident #2 now sat outside his room and looked in, and that he did not like this arrangement. These actions and inactions demonstrate the facility’s failure to implement its abuse prevention policies by not preventing the initial assault and by subsequently placing the two residents in close proximity after a known resident-to-resident assault.
Failure to Implement Behavior Care Plan and Identify Triggers for Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s physical behaviors. Resident #2, an individual with encephalopathy, aphasia, hemiplegia/hemiparesis following cerebral infarction, bipolar disorder, anxiety disorder, and moderate cognitive impairment (BIMS 9), had a care plan dated 8/26/24 identifying a potential to demonstrate physical behaviors related to agitation and combativeness, with a history of alleged physical aggression on 12/16/24, 8/8/25, and 9/26/25. The care plan interventions included a psych consult, analysis of key times, places, circumstances, triggers and de-escalators, and providing cues and choices. Despite this, the facility did not carry out the required analysis of circumstances and triggers after subsequent physical abuse incidents. On 8/8/25, documentation showed that Resident #2 suddenly slapped another resident (Resident #3) in the face while trying to get by in the hallway. The Provider Investigation Report indicated that the receptionist reported Resident #2 slapped Resident #3 after “having words,” and the Administrator’s interview with Resident #2 revealed he hit Resident #3 because he did not like what he said. Resident #3 reported they argued and Resident #2 hit him in the face. A later telephone interview with the former receptionist clarified that Resident #3 was sitting in his usual spot along the wall, Resident #2 wanted the same spot, they argued, and Resident #2 then leaned in and hit Resident #3 with a closed fist. The investigation report did not document any analysis of the circumstances or triggers surrounding this incident, despite the care plan requirement to do so. On 9/26/25, a progress note documented that Resident #2 got out of his wheelchair, walked up to another resident (Resident #1), and hit him in the face with his fist, stating the other resident was “always messing with me.” The Provider Investigation Report recorded that the Activity Director reported Resident #2 punched Resident #1, and that Resident #2 told the Administrator he hit Resident #1 because he was always “messing with him,” while Resident #1 stated he was on his phone and did not say anything to Resident #2. Subsequent interviews revealed that Resident #1 had limited mobility in his arms and hands and described Resident #2 walking across the patio and swinging at him after misinterpreting a phrase spoken into his phone. Staff interviews, including with CNAs, the DON, Social Worker, and MDS nurse, showed that while some staff were aware of a history of physical abuse, they were not aware of specific triggers or circumstances that could cause Resident #2 to become physically abusive, and the DON and Administrator acknowledged that triggers had not been identified or assessed after the incidents. This demonstrated that the care plan intervention to analyze circumstances and triggers after physical behavior incidents was not implemented.
Failure to Ensure Timely and Accurate Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for two residents. For one resident with multiple diagnoses including lymphedema, cachexia, irritable bowel syndrome, and other chronic conditions, several medications—Calcium Carbonate, Diphenoxylate/Atropine, and Dicyclomine—were administered 2 hours and 45 minutes later than scheduled on a specific date. The resident reported a history of delayed medication administration, stating that this issue had persisted for two months and that he had previously complained to nursing staff about not receiving his medications before breakfast as ordered. Another resident, with a complex medical history including osteoarthritis, hypertension, diabetes, and Alzheimer's disease, did not receive her prescribed dose of Lisinopril as ordered. During a medication pass, the medication aide initially prepared only half the required dose and was about to administer it when a nurse surveyor intervened, prompting the aide to correct the dosage. The aide had only recently started working at the facility and described her training as limited to initial orientation and shadowing. Interviews with staff revealed that medication administration competency is assessed upon hire, annually, and as needed, with additional oversight from corporate and consulting pharmacists. The facility's policy requires medications to be administered safely and in a timely manner as prescribed, but observations and record reviews demonstrated that these procedures were not consistently followed, resulting in late or incorrect medication administration for the affected residents.
Failure to Maintain Cleanliness of Plates in Kitchen
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. During an observation, two divided plates were found under the steam table with a small black substance and a metallic substance on them. These plates were intended for serving meals to residents. The Dietary Manager (DM) acknowledged that the presence of debris and metallic substances on the plates was inappropriate and could lead to cross-contamination or bacteria. The DM believed the substances might have come from the steam table or from foil taken off a dish coming out of the oven. The plates were subsequently removed and taken to the dishwashing area for re-washing and sanitization. The facility's Administrator (Admin) stated that he expected the kitchen to be clean at all times and that any spills or messes should be cleaned immediately. He confirmed that the substances on the plates should not have been present and that the plates should be cleaned prior to serving. The Admin mentioned that the dietary department was contracted but would be moving to an in-house department in the summer of 2024. Record reviews of the facility's Ware Washing and Manual Ware Washing policies from 2017 indicated that all dishware and utensils should be cleaned and sanitized after each use.
Improper Disposal of Rivastigmine Patches
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident, specifically in the disposal of Rivastigmine patches. During an observation and interview, three light brown patches with Rivastigmine printed on them were found on the floor of the resident's room. Two patches were undated, and one was dated 4/27/24. The Wound Care Nurse confirmed that these patches were for the resident's behaviors and placed them in a Ziploc bag. The nurse also stated that Rivastigmine patches should be disposed of in a sharps container, which is designed to safely dispose of sharp objects that could potentially cause injury or spread infection. Further interviews revealed inconsistencies in the staff's understanding of proper disposal procedures. The DON stated that patches should be disposed of in the trash and acknowledged that they should not be on the floor. The Administrator also mentioned that patches should be disposed of in the trash can for infection control reasons and did not know why the patches were on the floor. The facility's policy on administering medications, dated December 2012, was reviewed but did not provide specific guidance on the disposal of patches.
Significant Medication Error Involving Incorrect Dosage of Eliquis
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered the incorrect dosage of Eliquis. During a medication pass, a medication aide (MA) attempted to administer Eliquis 5 mg to a resident instead of the prescribed Eliquis 2.5 mg. The surveyor intervened before the medication was administered. The MA admitted to not having the correct dosage on the cart and proceeded to cut the 5 mg pill in half, despite not having proper authorization to do so. The Director of Nursing (DON) later confirmed that the resident's dosage had been changed from 5 mg to 2.5 mg due to previous bleeding issues, emphasizing the importance of following physician orders accurately. The resident involved had a history of Alzheimer's disease, heart failure, peripheral vascular disease, and cognitive communication deficit, with a BIMS score indicating intact cognition. The resident's care plan included anticoagulant therapy, and the physician's orders specified the correct dosage of Eliquis. The facility's policy on administering medications required verification of the right medication, dosage, time, and method before administration. The failure to adhere to these protocols could have resulted in severe consequences for the resident, highlighting a significant lapse in medication administration procedures at the facility.
Non-Functional Call Light for Resident
Penalty
Summary
The facility failed to ensure that Resident #18's call button by her bed was working. This deficiency was identified through observations, interviews, and record reviews. Resident #18, a [AGE] year-old female with severe cognitive impairment and multiple medical conditions including stroke, diabetes, and vascular dementia, was found to have a non-functional call light. The resident's care plan emphasized the importance of having the call light within reach and ensuring prompt responses to her requests for assistance. However, during observations on two consecutive days, the call light was found to be non-functional, and staff were unaware of this issue. Interviews with the CNA and LVN revealed that they were not aware of the malfunctioning call light and had last checked on the resident at different times without noticing the issue. The CNA mentioned that she checked on residents every two hours, while the LVN stated that call bells were checked daily at the beginning of the day. Despite these checks, the call light issue for Resident #18 was not identified or reported until the surveyor's observation. The Director of Nursing (DON) confirmed that leadership conducted daily checks of call bells during Angel Rounds but did not check every room, only a few randomly selected ones. The DON acknowledged that Resident #18's call light had not been checked in the last few days. The facility's policy on answering call lights emphasized the importance of ensuring call lights are within reach and functional, and that defective call lights should be reported promptly. However, this policy was not effectively implemented in the case of Resident #18, leading to the identified deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program for one resident, who was found with a medium-sized roach and approximately five small black ants crawling in her bed. The resident, who has Alzheimer's disease, cognitive communication deficit, major depressive disorder, anxiety, psychotic disorder, and reduced mobility, was observed lying in bed with pests. The Wound Care Nurse and a CNA confirmed the presence of the pests and took immediate action to clean the resident and change the bedding. The Director of Nursing (DON) acknowledged that bugs should not be present in the facility as it is unsanitary and could lead to residents being bitten. The Administrator admitted that the facility had a minor issue with sugar ants and sometimes residents left sweets out, but denied any problem with roaches. The facility's pest control service was called for an emergency treatment of the resident's room, and the exterminator identified the bugs as sugar ants. The facility's pest control policy mandates an ongoing program to keep the building free of insects and rodents, but the presence of pests in the resident's bed indicates a failure in maintaining this program effectively.
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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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| The Heights Of North Houston | 0.3 mi | ★★★★★ | 4 | 1 |
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