Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Cypress Pointe Rehabilitation And Nursing during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with dementia, depression, and muscle weakness, coded as requiring total assistance for rolling in bed, fell from bed during ADL care when a CNA turned away to rinse a washcloth. At the time of the fall, the bed was not lowered and ordered floor mats were not in place. Staff later documented progressive swelling, bruising, and pain in both lower legs and ankles, and imaging ultimately showed acute fractures of the distal tibia and fibula. Interviews with an LPN, MDS nurse, Rehab Manager, and DON confirmed that the resident was totally dependent, would not follow commands, and should have been safely positioned in the middle of the bed before the CNA turned away, indicating inadequate supervision and failure to follow fall‑prevention measures.
The facility failed to educate staff on COVID-19 vaccination, offer the vaccine after education, and maintain documentation of staff vaccination status. The DON was unable to locate COVID-19 information for all staff, and there was no documentation that staff received education on the benefits and potential risks of the vaccine or were offered the vaccine or information on how to obtain it. The DON stated staff were told to get the booster on their own because the facility does not offer it.
Two cognitively intact, dependent residents did not receive necessary ADL and incontinence care. One resident with a history of CVA, COPD, and GI bleed, care-planned for mechanical lift transfers and two-person toileting assistance, reported only receiving bed baths on night shift, being denied use of a shower chair despite requesting showers to protect her hair, and experiencing long delays in toileting and incontinence care from early morning until after lunch, even after activating the call light. Staff required use of a Hoyer lift, which the resident feared, and a CNA confirmed that incontinence care was routinely delayed and that the resident was not toileted because she used a Hoyer. Another resident with chronic pain, insomnia, COPD, obesity, and documented ADL self-care deficits reported remaining wet for prolonged periods, including from late night until morning, and stated that it often took 30–60 minutes or more for staff to respond, sometimes requiring her to call her son to contact the nurse’s station.
A cognitively intact resident with right-sided weakness and ADL deficits reported that CNAs routinely provided a bed bath, dressed her, and transferred her early in the morning but did not offer toileting every 2–3 hours as expected. She stated that when she used the call light for toileting or incontinence care, staff would respond, say they needed another CNA due to Hoyer lift use, and then not return for hours, often not until after lunch, resulting in frequent incontinence and straining for bowel movements. An Ombudsman confirmed frequent complaints about incontinence care, bathing, toileting, and repositioning. A CNA acknowledged that incontinence care was typically not provided until after lunch and that the resident was not toileted because she used a Hoyer lift, and also reported never seeing a toileting-specific Hoyer pad. Facility leadership later asserted that special equipment and less-restrictive transfer interventions were available for the resident but could not produce documentation to support this.
Failure to Report Allegations of Abuse and Missing Property: A resident with intact cognition reported verbal abuse by a CNA after refusing a late shower, but the allegation was not reported to the state agency within the required timeframe. Another resident with moderately impaired cognition reported missing personal and identification cards, yet staff did not timely escalate the allegation to administration or state agencies as required by policy.
A resident with Parkinson’s disease, major depressive disorder, and muscle weakness was found without hearing aids, and an RN said the aids could not be located and were believed lost. The care plan called for ensuring hearing aids were in place, but the DON and Administrator were unaware they were missing until later, and the DSW stated the facility had not helped the resident or representative locate resources, make appointments, or arrange transportation for replacement. The resident’s daughter reported the facility had lost hearing aids before and that she had purchased replacement aids more than once.
Binding Arbitration Agreement Not Clearly Explained: Staff failed to ensure that a binding arbitration agreement was clearly explained to three residents. One resident with stroke-related deficits and chronic pain did not recall signing a document waiving the right to a judge or jury trial, while two cognitively intact residents with BIMS scores of 15/15 stated they were unaware of or did not understand the agreement. The record lacked documentation that the residents understood the agreement, were told they could decline it by crossing it out, or were given a copy for review before the 30-day rescission period.
A resident with severe cognitive impairment, hemiplegia, and dependence for many ADLs had a change in condition during therapy, including sweating, increased tremors, non-verbal behavior, and reduced responsiveness. Staff placed the resident back in bed and later called the clinician and EMS, but the resident’s daughter-in-law said the facility did not notify the family before she arrived and found the resident not at baseline. The record also noted missed doses of tetrabenazine and conflicting staff accounts about the resident’s condition and monitoring.
A resident admitted after an acute care hospital stay with a chronic left foot ulcer had an inaccurate MDS assessment. The admission MDS coded the resident as unable to complete the BIMS, with memory problems and severely impaired daily decision making, and contained conflicting skin assessment coding in Section M regarding whether a pressure ulcer/injury or scar over a bony prominence was present. The MDSC acknowledged the assessment was coded inaccurately.
A resident with a hx of CVA with right-sided weakness, GI bleed, and COPD had a care plan for ADL deficits and transfers, but staff did not revise the person-centered care plan as the resident’s condition changed. CNA reported delayed incontinence care, no toileting because the resident used a Hoyer lift, and no special Hoyer pad was seen in the facility, while the DON and Administrator stated the resident was no longer allowed to use the sit-to-stand lift and was safer with the Hoyer lift.
A resident with severe cognitive impairment, immobility, and pressure ulcer risk developed worsening wounds on the left buttock/ischium and left heel that became necrotic, malodorous, and infected. Nursing notes and surveyor observations documented foul odor, drainage, redness, warmth, eschar, and fever before doxycycline was ordered, and the heel wound was not initially assessed when hospice evaluated the resident. The record showed the wounds had progressed to advanced stages before antibiotic treatment was initiated.
Planned breakfast items were not served as ordered for two residents. One resident with significant physical impairment and moderately impaired cognition received scrambled eggs instead of hard boiled eggs, and another resident with DM and morbid obesity received scrambled eggs instead of the ordered hard boiled eggs and bacon. Meal tickets reflected the ordered items, and staff interviews indicated the concern was not communicated to the kitchen as expected.
The facility failed to have a qualified infection preventionist (IP) to manage the infection prevention and control program. The current IP, a Registered Nurse, had not completed the required competency test for certification, despite having completed the training. This issue was identified during a review of infections, where two residents had multiple UTIs over six months. The last qualified IP left the facility, and the current IP assumed the role without certification. No concerns were raised by the administration regarding this deficiency.
A resident with multiple diagnoses, including peripheral vascular disease and pressure ulcers, did not receive prescribed pain medication for approximately 38 hours due to a mix-up in the medication administration record. The resident, who was cognitively intact, experienced significant pain and had an order for Oxycodone 10mg every four hours as needed. The error was discovered after the resident's family member intervened, leading to a review by the nursing supervisor and LPN, who then administered the medication.
A facility failed to document 50 doses of oxycodone on the MAR for a resident, despite these doses being signed out on control records. The resident had multiple medical conditions, including pain and pressure ulcers. The DON acknowledged the lack of an auditing process, and an LPN admitted to not consistently documenting due to feeling rushed. The findings were shared with the administration.
Failure to Provide Adequate Supervision During Bedside ADL Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a hazard‑free environment during ADL care for one dependent resident, resulting in a fall with fractures. The resident had diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, and muscle weakness, and was coded on the MDS as dependent for rolling left and right in bed, meaning the helper did all of the effort. The resident was also coded as rarely/never understood, so no BIMS was completed. Facility orders included the use of floor mats to the side of the bed while the resident was in bed for safety related to frequent falls. On the date of the incident, a CNA was providing ADL care to the resident while the resident was in bed. According to nursing documentation and staff interviews, the CNA turned her back to rinse a washcloth, during which time the resident rolled out of the bed onto the floor. LPN interview and nursing notes indicated that the bed had not been lowered and fall mats were not in use at the time of the fall, despite existing orders for floor mats. Staff, including the MDS nurse, Rehabilitation Manager, and DON, stated that the resident was totally dependent for ADLs, would not follow commands, and that the CNA should have ensured the resident was safely positioned in the middle of the bed before turning away. Following the fall, nursing documentation described that the resident was assessed and initially noted to have a small skin issue on the left lower arm, with no immediate signs of distress or pain. Over the next several days, nurses documented bilateral lower leg and ankle swelling, bruising, and obvious pain during ADL care. X‑rays of the bilateral ankles and feet were ordered and performed, and radiology results later identified acute‑appearing fractures of the distal tibia and fibula with posterior and medial angulation, as well as a fibular fracture. The resident was subsequently sent to the hospital and was reported to be admitted with bilateral tibial fractures. The facility’s own fall prevention and management policy referenced assessing fall risk factors including the resident’s current ADL status, but the actions taken during the ADL care did not prevent the fall for this dependent resident.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status. During the Infection Control task, surveyors requested the facility’s staff COVID-19 information on 2/21/26 at approximately 10:05 AM, and the DON stated later that day at 4:38 PM that she was unable to locate COVID-19 information for all staff. There was no documentation that staff had been provided education on the benefits and potential risks of the COVID-19 vaccine, and no documentation that staff were offered the vaccine or information on how to obtain it. During a final interview on 2/22/26 at 4:40 PM with the Administrator, DON, and Regional Nurse Consultant, the DON stated that staff were instructed to obtain the COVID-19 booster on their own because the facility does not offer it to staff.
Failure to Provide Timely ADL and Incontinence Care to Two Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary ADL care, including bathing, toileting, and incontinence care, to two cognitively intact, dependent residents. One resident, with a history of stroke with right-sided weakness, GI bleed, and COPD, had a care plan identifying ADL self-care deficits and specifying use of a mechanical sit-to-stand lift with two staff for transfers, two-person assist for toileting, and individualized interventions for bathing, dressing, and clothing selection. Despite this, the resident reported that night-shift CNAs routinely provided only bed baths, dressed her, and transferred her to a wheelchair around 5:30 AM, and that she was not offered showers as desired. She stated she wanted showers using a shower chair to avoid getting her hair wet and undoing professional hair styling, but staff insisted on using a shower bed and documented her as refusing showers when she would not agree to the shower bed. The same resident reported significant delays and lack of toileting assistance throughout the day. She stated she was aware of her need to toilet but had to wait so long for assistance that she often urinated in her incontinence brief and had to strain to have bowel movements while waiting for staff. She reported not being offered toileting every 2–3 hours as she had been told was the expectation and not receiving incontinence care from approximately 5:30 AM until after lunch, at which time her brief was described as extremely saturated. She also stated that when she activated the call light, staff would respond, acknowledge her need, say they needed to get help, and then not return for hours, often not until after lunch. The resident expressed fear of the Hoyer lift and stated she was strong enough to use a sit-to-stand lift, but staff required Hoyer use for transfers. The Ombudsman confirmed frequent complaints from this resident about incontinence care, bathing, toileting, and repositioning, and a CNA reported that the resident was not toileted because she used a Hoyer lift and that incontinence care was routinely delayed until after lunch. A second resident, originally admitted with diagnoses including chronic pain and insomnia and assessed as cognitively intact with a BIMS score of 15, was coded on the MDS as dependent for showering/bathing, toileting hygiene, lower body dressing, and footwear, and as needing assistance with personal and oral hygiene. The person-centered care plan identified an ADL self-care performance deficit related to COPD and obesity, with interventions including encouraging the resident to use the call bell and discussing concerns about loss of independence and decline in function. This resident reported that for about one and a half weeks she had not been changed for hours and had to lie in her own wetness, stating it took 30 minutes to an hour before staff checked on her and that she sometimes called her son to contact the nurse’s station. In a follow-up interview, she reported remaining wet from late at night until after 7:00 AM the next morning. The facility leadership was unable to provide additional information to refute or clarify these concerns during the final interview.
Failure to Provide Timely Toileting and Incontinence Care for Cognitively Intact Resident
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to assist Resident #79 in achieving and maintaining bowel and bladder control and dignity in toileting and incontinence care. Resident #79, who had a history of stroke with right-sided weakness, GI bleed, and COPD, was cognitively intact per a BIMS score of 15/15 and had a care plan identifying ADL self-care deficits with goals to improve function. The care plan interventions included use of a mechanical sit-to-stand lift with two staff for transfers and two-person assist for toileting, as well as support for bathing and dressing. Despite this, the resident reported that night-shift CNAs routinely provided a bed bath, dressed her, and transferred her to a wheelchair at 5:30 AM, and that she was not offered toileting every 2–3 hours as she had been told was the expectation by licensed nursing staff. Resident #79 stated she was aware of her need to toilet but had to wait extended periods for assistance because staff required use of a Hoyer lift, which needed two CNAs. She reported that when she used the call light, staff would respond, state they needed to get help, and then not return for hours, often not until after lunch, resulting in her frequently urinating in her brief and having to strain to have bowel movements while waiting. She further stated she did not receive any bowel or bladder care from 5:30 AM until after lunch, and that when incontinence care was finally provided, her brief was extremely saturated. The Ombudsman confirmed frequent complaints from the resident about incontinence care, bathing, toileting, and repositioning. CNA #4 acknowledged checking on the resident but not providing incontinence care until after lunch and stated the resident was not toileted because she used a Hoyer lift, and that she had never seen a special Hoyer pad for toileting or showers. During the final interview, facility leadership claimed such a special Hoyer pad and less-restrictive transfer interventions existed for the resident, but they were unable to provide any documentation or evidence of these interventions.
Failure to Report Allegations of Abuse and Missing Property
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident to the appropriate state agency. The resident had chronic pain and insomnia, scored 15 out of 15 on the BIMS, and was documented as cognitively intact for daily decision making. During an interview, the resident stated that she was not changed for hours and had to lie in her wetness about 1 1/2 weeks earlier, and she also described staff as not knowing how to talk to her appropriately. The complaint/grievance record for the incident stated that a CNA told the resident she needed to get her "ass washed" when the resident refused a shower after 10:00 p.m. The CNA denied making that statement and said the resident began yelling when asked to shower. The unit manager reported that the CNA approached the resident late in the evening, that the resident was upset, and that the CNA was not assigned to the resident the next night because of the incident. The unit manager also stated that she interviewed staff and consulted HR, but did not conduct interviews with other staff about the incident. The facility policy defined verbal abuse as disparaging or derogatory oral, written, or gestured communication and required alleged violations to be reported to the administrator, state agency, adult protective services, and other required agencies within 2 hours of the allegation. The administrator stated that the incident was not reported and that she and the DON were away when it occurred. The record also showed that seven staff members wrote that they did not witness anything. Facility staff also failed to ensure an allegation of missing property was reported timely to administrative staff and state agencies. Another resident, who had muscle weakness and type 2 diabetes and whose BIMS score of 12 indicated moderately impaired cognitive abilities for daily decision making, reported that two debit cards, a driver's license, and an insurance card were missing. The resident said she had told a nurse supervisor and other staff about the missing items about two weeks earlier and had contacted her bank. An LPN reported that she contacted supervisors from all shifts and that none were aware of the allegation, and she said the social worker was filing a grievance. A housekeeping employee stated that the resident complained about missing ID cards and a Medicaid card while the employee was in the room, that she helped look for them, and that she told one of the LPNs but should have told her boss. The facility policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent and required alleged violations to be reported to the administrator, state agency, adult protective services, and other required agencies within 2 hours. The administrator stated that the incident should have been reported by staff once they were informed and that a facility reported incident should have been initiated.
Lost Hearing Aids Not Addressed
Penalty
Summary
The facility failed to provide services to maintain hearing abilities for one resident. Resident #14, who was no longer in the facility at the time of review, had diagnoses including Parkinson’s disease without dyskinesia, major depressive disorder, and muscle weakness, and was coded as rarely/never understood with no BIMS completed. The care plan identified a communication problem related to head injury, weak voice, hearing impairment, decreased visual acuity, and increasing confusion, and included the intervention to ensure hearing aids were in both ears. During an observation tour, the resident was not wearing hearing aids, and an RN stated she could not find them and believed they had been lost. Interviews showed the Administrator and DON were unaware the hearing aids were missing until informed by the Unit Manager. The Administrator later stated she spoke with the resident’s daughter and discussed that the hearing aids were lost and that an audiology appointment would be set up. The daughter reported she had purchased hearing aids for the resident in 2018 and again in January 2023, and said the facility had lost them previously in 2021 and again in August 2024. The Director of Social Services stated that during a care plan meeting the daughter informed staff the hearing aids were missing, and that the facility had not assisted the resident or representative in locating resources, making appointments, or arranging transportation regarding replacement of the lost hearing aids. The facility policy stated that social services were responsible for assisting residents and families in locating resources and arranging appointments and transportation for vision and hearing services.
Binding Arbitration Agreement Not Clearly Explained
Penalty
Summary
The facility staff failed to ensure that the binding arbitration agreement was clearly explained to three residents in the survey sample. For Resident #97, who was admitted after an acute care hospital stay and had diagnoses including stroke with left hemiplegia, chronic back pain, and diarrhea, the admission screening showed the resident was alert, oriented to person, place, and situation, and verbally appropriate. During an interview, the resident stated he did not recall signing a document that would deprive him of the right to a trial by judge or jury in a dispute with the facility or his family. For Resident #3, who had diagnoses including chronic pain in the right foot, Bipolar I disorder, and COPD, the quarterly MDS coded a BIMS score of 15 out of 15, indicating intact cognitive abilities for daily decision-making. During an interview, the resident stated she was not knowledgeable of the binding arbitration agreement and how it affected her. Staff later stated that the resident was unfamiliar with the agreement and that it was explained to her in a manner she understood, but there was no documentation that she said she understood what an arbitration agreement was or that she was told she could decline by crossing out the document. For Resident #79, who had diagnoses including old stroke with residual right-sided weakness, GI bleed, and COPD, the significant change MDS also coded a BIMS score of 15 out of 15. The resident stated she was unaware of the binding arbitration agreement she had signed three years earlier. Staff stated the resident was unfamiliar with the agreement and that it was explained to her in a manner she understood, but there was no documentation that she understood the agreement or that she was told she had the right to decline it by crossing out the document, and a copy was not left with her for further review before the 30-day rescission period.
Failure to Notify Family Representative of Resident Change in Condition
Penalty
Summary
The facility failed to notify the resident’s family representative of a change in condition for one resident in the survey sample. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and cognitive communication deficit. The quarterly MDS coded the resident with a BIMS score of 2 out of 15, indicating severely impaired cognitive abilities for daily decision making, and the care plan described the resident as dependent for multiple ADLs and requiring total assistance with transfers. On the day of the event, the resident was waiting for transportation to a doctor’s appointment when therapy staff observed a change in condition. A COTA documented that the resident was sweating, non-verbal, had increased tremors, and was not responding as usual. The resident was placed back in bed with aide assistance, and the COTA also noted discoloration of the resident’s hands and arms. PT later documented that the resident was alert but not verbally responding and was unable to complete tasks. The timeline also showed that the resident’s daughter-in-law signed in as a visitor later that afternoon, and the resident was sent to the emergency room after staff notified the clinician and paramedics arrived. Interviews showed conflicting accounts about what staff observed and when the resident’s condition changed, but the daughter-in-law stated she was not called by the facility before arriving and found the resident not at baseline, staring and sleepy. She said staff told her the resident had been like that since noon and that no one checked on her between noon and her arrival. The record also showed missed doses of tetrabenazine on two days in February, and the APS worker reported concerns related to an incident during therapy in which the resident appeared to overexert herself and became unresponsive to commands. The deficiency cited was the failure to notify the resident’s family representative of the change in condition.
Inaccurate MDS Coding for Resident Skin and Cognition Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident with a closed record. The resident was admitted after an acute care hospital stay and had diagnoses including a non-pressured chronic ulcer of the left foot. On the admission MDS with an ARD of 2/28/25, the resident was coded as unable to complete the BIMS, with the staff interview indicating long- and short-term memory problems and severely impaired daily decision making. The assessment also contained conflicting coding in Section M, where one entry indicated the resident did not have a pressure ulcer/injury or scar over a bony prominence, while the modified Section M skin assessment coded the resident as having a pressure ulcer/injury or scar over a bony prominence. During interview, the MDSC agreed the assessment had been coded inaccurately.
Failure to Revise Care Plan After Transfer Device Change
Penalty
Summary
The facility failed to review and revise Resident #79’s person-centered care plan as the resident’s condition changed. Resident #79 was admitted after an acute care hospital stay and had diagnoses including an old stroke with residual right-sided weakness, GI bleed, and COPD. A significant change MDS assessment with an ARD of 11/12/2025 coded the resident as having intact cognitive abilities for daily decision-making, with a BIMS score of 15 out of 15. The resident’s care plan included ADL self-care performance deficits related to activity intolerance, confusion, fatigue, and CVA with right-sided hemiparesis, and it listed interventions for transfers, bathing, and dressing. During interview, CNA #4 stated she checked on Resident #79 throughout the day but did not provide incontinence care until after lunch, close to 1:00 PM. She also stated the resident was not toileted because she used a Hoyer lift for transfers and said she had never seen a special Hoyer pad in the facility designed for toileting and showers. In a later interview, the Administrator stated the facility had received a message from the hospital that the resident was no longer allowed to use the sit-to-stand lift and that the facility had the special Hoyer pad for the resident to use. However, the facility staff did not provide documentation or interventions they said were offered to the resident, and they did not revise the care plan when they determined the resident was safer using the Hoyer lift.
Delayed Antibiotic Treatment for Infected Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely antibiotic treatment for two infected advanced-stage wounds on a resident’s left buttock/ischium and left heel. The resident had severe cognitive impairment, was chairfast, had diagnoses including pressure ulcer of the left heel and pressure ulcer of the left ischium/buttock, and was coded as being at risk for pressure ulcer/injury on MDS assessments. The care plan identified pressure ulcers on the left buttock and left heel, with interventions to monitor and document wound changes, signs of infection, wound measurements, and weekly treatment documentation. The resident also had an air mattress ordered for wound care/prevention and was under comfort care/hospice involvement during the period described. The left buttock wound was documented as worsening from redness to an unstageable pressure ulcer with necrotic tissue, foul odor, and drainage. Nursing notes described foul smell and redness around the wound, and a wound observation on 2/20 found the wound malodorous and appearing necrotic. A hospice note later described fever, low blood pressure, a 7 cm by 7.5 cm wound with 100% necrotic tissue, peri-wound erythema, warmth, and foul odor. Although doxycycline was ordered on 2/21 for wound infection, the wound had already shown signs of infection before that order was obtained. The left heel wound also deteriorated over time. It was first observed as a pressure injury and later described as worsening, then unstageable with eschar and drainage. On 2/20, the wound was observed to be malodorous with necrotic/black tissue and drainage on the pillow where the heel rested. Nursing progress notes later documented the heel wound as 90% eschar with 10% slough and odor noted. The hospice nurse initially assessed only the buttock wound and not the heel, and the record reflects that the heel wound had been present and worsening before the infection-related treatment was addressed. Surveyor observations, staff interviews, and record review showed the wounds were infected and advanced before antibiotics were started.
Planned Breakfast Menu Not Followed for Two Residents
Penalty
Summary
The facility failed to serve portions of the planned menu for two residents during breakfast. Resident #32, who was admitted after an acute care hospital stay and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and contracture of the left upper arm, was assessed as having moderately impaired cognitive abilities for daily decision making and required extensive assistance with most activities of daily living. During a breakfast observation, the resident’s tray contained scrambled eggs, sausage, an English muffin, coffee, and orange juice, while the meal ticket specified hard boiled eggs, sausage patty, English muffin, milk, and coffee. Resident #64, who had diagnoses of type 2 diabetes mellitus and morbid obesity and was cognitively intact on the MDS, was observed at breakfast with a tray containing scrambled eggs, sausage, an English muffin, oatmeal, apple juice, and hot chocolate. The meal ticket specified hard boiled eggs, mechanical sausage patty with cream gravy, bacon x2, English muffin, apple juice, hot chocolate, and an Ensure shake. The resident stated that meals sometimes came this way but that she really wanted bacon and boiled eggs. During interviews, CNA #1 said she would normally contact the kitchen if a resident requested something different, and the Dietary Manager stated nursing staff should have communicated the concern so he could have prepared a boiled egg and educated dietary staff.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) to oversee the infection prevention and control program. During a review of infections acquired in the facility, it was found that the current IP, a Registered Nurse, had not completed the competency test required for certification, despite having completed the training. This deficiency was highlighted during an interview on 7/3/24, where the IP could not provide documentation of the curriculum for staff education on urinary tract infections (UTIs), despite two residents having multiple UTIs over a six-month period. The last qualified IP had left the facility on 12/22/23, and since then, the current IP had been fulfilling the role without the necessary certification. In a final interview on 7/8/24 with the Administrator, Director of Nursing, and Regional Nurse Consultant, no comments or concerns were raised regarding the lack of a qualified IP. This indicates a lapse in ensuring that the infection prevention and control program is managed by a certified individual, potentially impacting the quality of care provided to residents.
Failure to Administer Pain Medication
Penalty
Summary
The facility staff failed to administer pain medication to a resident, identified as Resident #7, who experienced significant pain and requested medication. Resident #7, who was cognitively intact, was admitted with multiple diagnoses including left leg pain, peripheral vascular disease, a right below-knee amputation, and pressure ulcers. Despite having an order for Oxycodone 10mg every four hours as needed for pain, the resident went without pain medication for approximately 38 hours. The issue arose when the nursing staff mistakenly believed that Resident #7 had already received his medication, leading to a prolonged period of unmanaged pain. The confusion was compounded by a mix-up in the medication administration record and the narcotic book, where it was incorrectly noted that Resident #7 had received his pain medication. This error was discovered after the resident's family member intervened, prompting a review of the records by the nursing supervisor and LPN. It was then realized that the medication had not been administered, and the resident was subsequently given the prescribed Oxycodone. The facility's pain management policy, which mandates pain management for residents requiring such services, was not adhered to in this instance, as evidenced by the lack of a pain assessment and the failure to administer medication as ordered.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility staff failed to document the administration of 50 doses of oxycodone on the Medication Administration Record (MAR) for one resident, despite these doses being signed out on the medication monitoring control records for December 2023 and January 2024. The resident, who was admitted with conditions including left leg pain, peripheral vascular disease, a right below-the-knee amputation, and pressure ulcers, had a care plan focusing on the risk for alteration in comfort. However, the MARs for the specified months did not reflect the administration of oxycodone on numerous occasions, indicating a lapse in proper documentation. Interviews conducted during the survey revealed that the Director of Nursing (DON) acknowledged the lack of a process for auditing controlled medication sheets and expressed intentions to develop one. Additionally, an LPN admitted to not consistently documenting controlled medications on the MAR due to feeling rushed and the fast-paced nature of her shifts. This LPN had previously been educated by the DON on the importance of complete documentation. The findings were shared with the facility's administration, but no further information was provided before the survey concluded.
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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 Virginia Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Taylor Hosp | 1.9 mi | ★★★★★ | 5 | 0 |
| Waterside Health & Rehab Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Bayside Health & Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Norfolk | 2.4 mi | ★★★★★ | 0 | 0 |
| Thalia Gardens Rehabilitation And Nursing | 3.4 mi | ★★★★★ | 31 | 0 |
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