Inspection Reports for
Cypress at Lake Providence
5976 US-65 NORTH, LAKE PROVIDENCE, LA, 71254
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Inspection Report — May 21, 2025
Annual Inspection CMS
Date: May 21, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to obtain consent for psychotropic medications, inadequate resident notification of room changes, failure to post survey results, inaccurate resident assessments, environmental cleanliness issues, medication management errors, incomplete care plans, improper medication storage, pest control deficiencies, and lack of required staff training.
Deficiencies (23)
F 0552: The facility failed to ensure residents were fully informed and consented to psychotropic medications for 5 residents (#3, #32, #36, #61, #63).
F 0559: The facility failed to provide written notice to Resident #41 before changing her room as required by policy.
F 0577: The facility failed to post results of three surveys conducted after the last annual survey, limiting resident access to survey information.
F 0582: The facility failed to provide required Medicare non-coverage notices to Resident #16 upon discharge from Medicare Part A services.
F 0584: The facility failed to maintain a safe, clean, and homelike environment for 3 residents (#35, #41, #63) due to grime, dust, dead insects, and unclean bathroom fixtures.
F 0605: The facility failed to monitor for side effects and behaviors of psychotropic medications for Resident #61 as required.
F 0641: The facility failed to ensure accurate Minimum Data Set (MDS) assessments for falls and pressure ulcers for Residents #19, #35, #61, and #62, and failed to complete required risk assessments quarterly.
F 0656: The facility failed to implement care plans for Resident #13 to wear a smoking apron while smoking and for Resident #62 to have a fall mat at bedside.
F 0677: The facility failed to provide adequate bathing and nail care for 4 residents (#3, #27, #40, #52) as required by their care plans.
F 0689: The facility failed to provide a safe environment free from accident hazards by not addressing falls with appropriate interventions for Residents #13 and #61.
F 0695: The facility failed to provide safe and appropriate respiratory care by improperly storing nebulizer mouthpieces and failing to post oxygen use signage for 3 residents (#15, #27, #171).
F 0700: The facility failed to assess residents for entrapment risk, obtain informed consent, physician orders, and care plan documentation for bed rail use for 3 residents (#8, #18, #321).
F 0726: The facility failed to ensure nursing staff followed physician orders for Resident #32 by not notifying the physician of high blood glucose readings as required.
F 0732: The facility failed to post nurse staffing information daily in a prominent and accessible location.
F 0755: The facility failed to provide pharmaceutical services meeting resident needs by lacking medications for administration for Residents #8 and #33.
F 0756: The facility failed to ensure pharmacist monthly drug regimen reviews included documentation of rationale for declining dose reductions and identification of monitoring irregularities for Residents #3, #32, and #36.
F 0757: The facility failed to monitor Resident #61 for edema while on a diuretic, with no documented edema monitoring for multiple days in April and May 2025.
F 0759: The facility had a medication error rate of 7% due to omission of Vitamin D-2 for Resident #33 and Farxiga for Resident #8 during medication passes.
F 0761: The facility failed to properly store medications by leaving medications at residents' bedside for Residents #55 and #64.
F 0868: The facility failed to hold quarterly Quality Assessment and Assurance meetings with required members since the prior annual survey.
F 0880: The facility failed to maintain infection control by improperly storing used tube feeding syringes for Resident #44.
F 0925: The facility failed to maintain an effective pest control program as flies were observed throughout the facility and in multiple resident rooms (#15, #20, #52).
F 0947: The facility failed to ensure required dementia management, abuse prevention, and competencies/skills training for 2 of 5 reviewed nurse aides.
Report Facts
Medication error rate: 7
Falls: 4
Edema monitoring omissions: 29
Accu-check values > 401: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed multiple findings including lack of consent, medication errors, care plan failures, and training deficiencies |
| S7 Regional Director of Clinical | Regional Director of Clinical | Confirmed findings related to medication monitoring, pharmacist irregularities, and bed rail assessments |
| S1 Administrator | Administrator | Confirmed failure to post survey results and pest control issues |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Reported medication omissions during medication pass |
| S15 LPN/MDS | Licensed Practical Nurse / MDS Coordinator | Confirmed inaccurate MDS assessments and missing risk assessments |
| S2 Certified Nursing Assistant | Certified Nursing Assistant | Reported resident bathing schedules and medication administration observations |
Inspection Report — Apr 23, 2025
Complaint Investigation CMS
Date: Apr 23, 2025
Visit Reason
The investigation was conducted due to allegations of verbal abuse by a Certified Nursing Aide (CNA) toward a resident, failure to timely report suspected abuse and injuries of unknown source, and failure to provide appropriate pain management for residents.
Complaint Details
The complaint investigation was substantiated for verbal abuse by a CNA toward resident #5. The facility failed to immediately report the verbal abuse allegation and an injury of unknown source involving resident #1 to the administrator and State Survey Agency within 2 hours as required. The CNA was suspended during the investigation.
Findings
The facility failed to protect a resident from verbal abuse by a CNA, failed to timely report allegations of abuse and injuries to the administrator and State Survey Agency within required timeframes, and failed to provide appropriate pain management for a resident due to unavailability of prescribed pain medication.
Deficiencies (3)
F0600: The facility failed to protect a resident from verbal abuse by a CNA who raised his voice and used inappropriate language toward the resident during care.
F0609: The facility failed to timely report suspected abuse and injuries of unknown source to the administrator and State Survey Agency within 2 hours as required by policy and state law.
F0697: The facility failed to provide safe and appropriate pain management when a resident did not have prescribed pain medication available for several days.
Report Facts
Medication administrations: 45
Medication unavailability days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA) | Involved in verbal abuse incident with resident #5 | |
| Agency Licensed Practical Nurse (LPN) | Overheard CNA cussing at resident #5 and reported to Director of Nursing | |
| Director of Nursing (DON) | Notified administrator of verbal abuse incident and failed to report timely | |
| Administrator | Notified late about verbal abuse incident and failed to report timely to State Survey Agency | |
| Licensed Practical Nurse (LPN) | Provided care to resident #4 and confirmed medication unavailability | |
| Corporate Registered Nurse | Confirmed failure to timely report injury of unknown source involving resident #1 |
Inspection Report — Apr 1, 2025
Complaint Investigation CMS
Date: Apr 1, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of sexual abuse by one resident against another in the facility.
Complaint Details
The complaint investigation was substantiated. Resident #1 alleged that resident #2 entered her room twice, touching her breast and genitals. The facility failed to provide one-to-one supervision to resident #2 after the first incident, allowing a second incident to occur. The facility took corrective actions including police involvement, staff education, and increased monitoring.
Findings
The facility failed to protect resident #1 from sexual abuse by resident #2 and failed to provide required one-to-one supervision to resident #2 after the allegation. This resulted in an Immediate Jeopardy situation when resident #2 re-entered resident #1's room unsupervised. The facility implemented corrective actions prior to the State Agency's investigation entry.
Deficiencies (2)
F 0600: The facility failed to protect residents from all types of abuse including sexual abuse and failed to provide one-to-one supervision to resident #2 after an allegation of sexual abuse, resulting in immediate jeopardy to resident health or safety.
F 0607: The facility failed to implement written policies and procedures to prevent abuse and failed to provide one-to-one supervision to resident #2 after an allegation of sexual abuse, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents affected: 4
BIMS score resident #1: 10
BIMS score resident #2: 9
Dates of incidents: 03/14/2025 at 10:44 p.m. and 03/15/2025 at 4:47 a.m.
Date of police removal: Resident #2 removed on 03/14/2025 and returned on 03/15/2025 at 12:33 a.m.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Named in investigation and corrective action oversight |
| S1 Administrator | Administrator | Named in investigation and corrective action oversight |
| S3 CNA | Certified Nurse Aid | Assigned to monitor resident #2 one-to-one but failed to do so |
| S5 LPN | Licensed Practical Nurse | Documented initial abuse report and participated in investigation |
Inspection Report — Sep 26, 2024
Complaint Investigation CMS
Date: Sep 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse involving two residents.
Complaint Details
The complaint investigation found that the facility did not report the abuse incident involving resident #7 hitting resident #6 within the required 2-hour timeframe. The incident was reported to the state survey agency the following day. The finding was substantiated.
Findings
The facility failed to report an alleged abuse incident involving resident #7 hitting resident #6 with a walker within the required 2-hour timeframe to the state survey agency. Both residents were assessed with no injuries found, but the incident was reported late.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse involving resident #7 hitting resident #6 with a walker. The incident was not reported to the state agency within 2 hours as required by state law.
Report Facts
Residents reviewed for allegations of abuse: 9
Residents involved in incident: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (S3LPN) | Assessed residents after the incident and found no injuries. | |
| Director of Nursing (S2DON) | Was informed of the incident on the evening of 08/31/2024. | |
| Administrator (S1Administrator) | Confirmed the incident was not reported within 2 hours to the state agency. |
Inspection Report — May 8, 2024
Routine CMS
Date: May 8, 2024
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident rights, abuse prevention, care planning, medication administration, staffing, environmental safety, food safety, and pest control. Several residents experienced inadequate care, unsafe equipment, and environmental hazards.
Deficiencies (18)
F 0577: Facility failed to post the most recent survey results in a place accessible to residents and family.
F 0578: Facility failed to ensure residents' advance directives were obtained and available for staff review for 2 residents.
F 0582: Facility failed to provide required Medicare non-coverage notices to 2 residents discharged with benefit days remaining.
F 0584: Facility failed to maintain a safe, clean, and homelike environment in 4 residents' rooms with environmental hazards including holes in walls and unsecured fixtures.
F 0600: Facility failed to protect a resident from physical abuse by a CNA, resulting in actual harm with bruises and scratches.
F 0609: Facility failed to timely report suspected abuse and ensure all alleged violations were reported immediately to administration for 1 resident.
F 0636: Facility failed to conduct timely and comprehensive smoking safety assessments for 1 resident who smokes.
F 0677: Facility failed to provide adequate personal care and grooming for 5 residents who were unable to perform activities of daily living.
F 0684: Facility failed to provide treatment and care according to orders and care plans for 3 residents including wound care and positioning devices.
F 0726: Facility failed to ensure nursing staff had appropriate competencies and documentation of medication administration for 1 resident.
F 0727: Facility failed to ensure a Registered Nurse was on duty for 8 consecutive hours on 4 dates in December 2023.
F 0729: Facility failed to conduct monthly State Adverse Actions checks for 3 CNAs as required.
F 0756: Facility pharmacist failed to report irregularities and ensure monitoring for unnecessary medications for 3 residents.
F 0757: Facility failed to ensure residents' drug regimens were free from unnecessary drugs by not performing required edema checks and lab monitoring for 3 residents.
F 0812: Facility failed to procure food from approved sources and maintain food safety standards including temperature logs, sanitizer checks, and food handling.
F 0836: Facility failed to provide sufficient nursing staff hours and ensure residents received care according to care plans for 2 residents.
F 0908: Facility failed to maintain resident care equipment in safe operating condition for 2 residents with damaged wheelchair parts.
F 0925: Facility failed to maintain an effective pest control program resulting in multiple flies observed in resident areas.
Report Facts
Deficiency cited: 17
Residents affected: 82
Days short staffed: 11
Dates RN not on duty 8 hours: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1Administrator | Administrator | Confirmed staffing and policy issues |
| S2DON | Director of Nursing | Interviewed regarding multiple care and staffing deficiencies |
| S13ADON | Assistant Director of Nursing | Provided information on medication and wound care deficiencies |
| S11DM | Dietary Manager | Interviewed regarding food safety deficiencies |
| S15CNA | Certified Nursing Assistant | Reported wound and wheelchair concerns |
| S16LPN | Licensed Practical Nurse | Confirmed medication administration and wound care issues |
| S22LPN | Licensed Practical Nurse | Confirmed lack of hand roll use for resident |
| S18Regional Director of Clinical | Regional Director of Clinical | Confirmed pest control and care deficiencies |
Inspection Report — Feb 7, 2024
Complaint Investigation CMS
Date: Feb 7, 2024
Visit Reason
The inspection was conducted to investigate allegations of physical abuse and failure to properly monitor psychotropic medication use and behavioral health training at Cypress at Lake Providence nursing home.
Complaint Details
The complaint investigation found substantiated physical abuse incidents between residents, inadequate investigations of abuse allegations, failure to monitor psychotropic medication effects, and lack of behavioral health training for staff.
Findings
The facility failed to protect residents from physical abuse by other residents, failed to thoroughly investigate allegations of abuse, failed to monitor psychotropic medication effectiveness and side effects for one resident, and failed to provide adequate behavioral health training to staff.
Deficiencies (4)
F 0600: The facility failed to protect 7 of 10 sampled residents from physical abuse by other residents, including multiple documented altercations with no injuries but confirmed physical abuse.
F 0610: The facility failed to have documented evidence that allegations of physical abuse were thoroughly investigated for 4 of 10 sampled residents, lacking interviews and documentation as required by policy.
F 0758: The facility failed to ensure a resident receiving psychotropic medication was monitored for effectiveness and side effects as ordered.
F 0949: The facility failed to implement and maintain an effective behavioral health training program for all staff, including direct care, therapy, and contract staff, prior to working with residents.
Report Facts
Residents affected by abuse: 7
Residents with uninvestigated abuse allegations: 4
Residents receiving psychotropic medications: 41
Residents with psychiatric/mood disorders: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed physical abuse incidents and lack of investigations and training |
| S2 Director of Nursing | Director of Nursing | Confirmed lack of psychotropic medication monitoring and behavioral health training |
| S5 Certified Nursing Assistant | CNA | Witnessed physical altercation between residents #1 and #2 |
| S3 Licensed Practical Nurse | LPN | Witnessed physical altercation between residents #7 and #2 |
| S7 Physical Therapy Assistant | PTA | Witnessed physical altercation between residents #3 and #4; reported lack of behavioral health training |
| S18 Activity Director | Activity Director | Witnessed physical altercation between residents #5 and #6 |
Inspection Report — Oct 4, 2023
Complaint Investigation CMS
Date: Oct 4, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's responsible party of a change in condition following a fall and emergency room visit.
Complaint Details
The complaint investigation found the facility did not notify Resident #1's responsible party of the fall and emergency room visit on 09/12/2023. The responsible party notification was substantiated as not completed.
Findings
The facility failed to inform the responsible party of Resident #1's fall and subsequent emergency room visit on 09/12/2023. Documentation and interviews confirmed no notification was made despite the resident's condition change.
Deficiencies (1)
F 0580: The facility failed to notify Resident #1's responsible party of the resident's fall and emergency room visit on 09/12/2023. Documentation and staff interviews confirmed the responsible party was not informed.
Report Facts
Residents sampled: 4
Resident affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN (Licensed Practical Nurse) | Attempted to notify responsible party but did not complete notification | |
| S2DON (Director of Nursing) | Reviewed incident report and confirmed responsible party should have been notified |
Inspection Report — Aug 30, 2023
Complaint Investigation CMS
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical and verbal abuse by a Certified Nursing Assistant (S3 CNA) toward a resident.
Complaint Details
The complaint investigation was substantiated. The incident involved physical and verbal abuse by S3 CNA toward resident #1 on 08/03/2023. The CNA was terminated following the investigation. The facility failed to establish coordination with the quality assurance and performance improvement (QAPI) program after the incident.
Findings
The facility substantiated that S3 CNA physically and verbally abused resident #1 by using profanity, cursing, pushing a bedside table into the resident, and overturning the table's contents onto the resident's lap. The facility failed to implement a quality assurance plan to monitor and prevent abuse after the incident.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse. An incident on 08/03/2023 involved S3 CNA cursing at resident #1, pushing a bedside table into him, and overturning his personal belongings onto his lap.
Report Facts
Residents reviewed for abuse: 5
Residents involved in incident: 1
Date of incident: Aug 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 CNA | Certified Nursing Assistant | Named in physical and verbal abuse finding |
| S2 Director of Nursing | Director of Nursing | Interviewed regarding abuse incident and investigation |
| S1 Administrator | Administrator | Confirmed substantiation of abuse and lack of QAPI implementation |
| S4 Housekeeping Supervisor | Housekeeping Supervisor | Witnessed incident and cursing between resident and CNA |
Inspection Report — May 23, 2023
Annual Inspection CMS
Date: May 23, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide written advance directive information, failure to notify resident representatives of falls and hospitalizations, inadequate environmental cleanliness, failure to update care plans after falls, failure to provide necessary personal care, inadequate wound care and assessments, failure to monitor wanderguards, incomplete staff registry verifications, medication management issues including lack of monitoring for side effects and behaviors, medications left unattended, and ineffective quality assurance performance improvement (QAPI) processes.
Deficiencies (15)
F 0578: The facility failed to ensure residents or their representatives were provided written Advance Directive information for 3 residents reviewed.
F 0580: The facility failed to notify resident representatives after falls for 2 residents with falls.
F 0584: The facility failed to maintain a safe, clean, comfortable environment by having dirty whirlpool room, dirty resident bathrooms, lack of soap and paper towels, and large holes in bathroom walls.
F 0623: The facility failed to provide timely notification to resident representatives and Ombudsman before transfer or hospitalization for 2 residents.
F 0657: The facility failed to update the plan of care with appropriate approaches after a resident fall for 1 resident reviewed for falls.
F 0677: The facility failed to provide necessary services for a resident unable to perform activities of daily living, evidenced by failure to provide clean bed linens.
F 0684: The facility failed to provide appropriate treatment and care according to orders for 3 residents with pressure ulcers, including lack of weekly RN wound assessments and weekend wound care.
F 0689: The facility failed to ensure adequate supervision and monitoring of wanderguards for 2 residents at risk for elopement.
F 0729: The facility failed to ensure State Registry verifications were obtained prior to hire for 2 CNAs.
F 0756: The facility failed to ensure a licensed pharmacist performed monthly drug regimen reviews and acted on irregularities for 4 residents reviewed for unnecessary medications.
F 0757: The facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 resident due to failure to obtain required lipid panel and liver function tests.
F 0758: The facility failed to ensure resident #68 was monitored for side effects and behaviors while on an antianxiety medication.
F 0761: The facility failed to ensure all drugs and biologicals were stored in locked compartments and medications were not left unattended at the bedside for 1 resident.
F 0867: The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) system and did not have documentation of QAPI activities or minutes.
F 0868: The facility failed to have the required QAPI members and failed to coordinate and evaluate QAPI activities.
Report Facts
Residents reviewed for advance directives: 3
Falls for resident #13: 4
Residents reviewed for falls: 3
Residents reviewed for hospitalizations: 2
Residents reviewed for wound care: 3
Residents reviewed for wanderguard monitoring: 2
Personnel files reviewed for CNA registry verification: 5
Personnel files missing CNA registry verification: 2
Residents reviewed for unnecessary medications: 5
Medications left unattended: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 RN | Registered Nurse Manager | Interviewed regarding notification failures, wound care, medication diagnoses, and medication left unattended |
| S5 Corporate Compliance | Licensed Practical Nurse | Interviewed regarding advance directives, wanderguard monitoring, wound care, medication monitoring, and medication left unattended |
| S1 Administrator | Administrator | Interviewed regarding QAPI deficiencies and medication left unattended |
| S7 Assistant Administrator | Assistant Administrator | Interviewed regarding notification failures |
| S6 Corporate MDS Coordinator | MDS Coordinator | Interviewed regarding wound care and lab monitoring |
| S9 Business Office Manager | Business Office Manager | Interviewed regarding CNA registry verification |
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