Inspection Reports for Cypress Garden Center for Nursing & Rehabilitation
NY, 11354
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 1, 2025, identified deficiencies related to resident abuse, specifically involving a licensed practical nurse pulling a combative resident into and out of an elevator, which was substantiated by video evidence and led to staff removal, suspension, police notification, and training. Earlier inspections showed a pattern of deficiencies in care planning, resident rights, environmental cleanliness, and assistance with activities of daily living, with issues such as failure to honor resident self-determination, unsafe and unsanitary conditions, and incomplete care for hearing impairments. Complaint investigations were mostly unsubstantiated except for the substantiated abuse case in the latest inspection. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows recurring challenges in resident care and environment, with corrective actions taken but no clear sustained improvement trend.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
One isolated Level 2 deficiency for free from abuse and neglect, corrected as of March 23, 2025.
Findings
One isolated Level 2 deficiency for free from abuse and neglect, corrected as of March 23, 2025.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
The abbreviated survey was conducted to investigate an incident of potential resident abuse involving Licensed Practical Nurse #1 pulling Resident #1 into and out of an elevator while Resident #1 was combative.
Complaint Details
The visit was complaint-related due to an allegation of abuse involving Licensed Practical Nurse #1 and Resident #1. The complaint was substantiated based on video evidence and staff interviews.
Findings
The facility failed to protect Resident #1 from abuse by Licensed Practical Nurse #1, who pulled the resident into and out of an elevator despite the resident's combative behavior. Video surveillance confirmed the incident, and immediate corrective actions were taken including removal of the nurse, suspension of involved staff, police notification, and staff in-services on abuse prevention.
Deficiencies (1)
Failure to protect a resident from abuse by staff, specifically Licensed Practical Nurse #1 pulling Resident #1 into and out of an elevator while combative.
Report Facts
Residents affected: 5
Staff in-serviced: 180
Date of incident: Mar 19, 2025
Date of video review: Mar 31, 2025
Date of survey completion: Apr 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in abuse incident involving pulling Resident #1 into and out of elevator. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Witnessed the incident and was involved in the investigation; suspended pending investigation. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Witnessed the incident and provided statements; suspended pending investigation. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Witnessed the incident and provided statements; suspended pending investigation. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Sep 23, 2024
Visit Reason
Multiple isolated and pattern Level 2 deficiencies in quality of care and life safety code, all corrected by November 22, 2024.
Findings
Multiple isolated and pattern Level 2 deficiencies in quality of care and life safety code, all corrected by November 22, 2024.
Deficiencies (9)
Care plan timing and revision
Criminal history record check process
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Safe/functional/sanitary/comfortable environ
Treatment/devices to maintain hearing/vision
Building construction type and height
Fire drills
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The inspection was conducted as a recertification survey from 09/16/2024 to 09/23/2024 to assess compliance with resident rights and care standards.
Findings
The facility failed to ensure a resident's right to self-determination was honored, as evidenced by a Certified Nursing Assistant repeatedly attempting to provide care to a resident who refused it. The resident communicated refusal through gestures and an iPad, but care was still attempted.
Deficiencies (1)
Facility did not ensure a resident's right to self-determination was honored; Certified Nursing Assistant repeatedly attempted to render care despite resident refusal.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Named in deficiency for attempting care despite resident refusal. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding resident refusal of care and notification process. |
| Director of Nursing Service | Director of Nursing Service | Interviewed about policies on resident refusal of care and staff education. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 23, 2024
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements related to the safety, cleanliness, care planning, and resident services at Cypress Garden Center for Nursing and Rehab.
Findings
The facility was found to have multiple deficiencies including unsafe and unsanitary environmental conditions across several floors and units, failure to update a resident's comprehensive care plan to reflect hearing impairment, and failure to ensure proper use and maintenance of hearing aids for residents. Environmental issues included dirt, dust, rust, broken furniture, stained walls, and unsafe wiring. Staff interviews confirmed challenges in maintaining cleanliness and updating care plans.
Deficiencies (4)
Residents' environment was not maintained in a safe, sanitary, and comfortable manner with dirt, dust, rust, broken furniture, stained walls, and unsafe wiring observed on multiple floors and units.
Comprehensive Care Plan for Resident #207 was not reviewed and revised to reflect the resident's hearing impairment and need for a hearing aid.
Resident #160 was not consistently assisted with the use of the prescribed hearing aid, which was observed missing during multiple occasions.
Nursing home areas including nurse stations, lobby restrooms, staff bathrooms, and floors were not kept safe, clean, and comfortable, with broken floor tiles, offensive odors, loose fixtures, embedded dirt, and exposed wiring.
Report Facts
Units with environmental issues: 3
Residents reviewed for Communication vision/hearing: 3
Residents reviewed for Communication and Hearing Care Area: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported Resident #207's hearing problem and audiology consult |
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Noted Resident #207's hearing impairment and need to update care plan |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged care plan for Resident #207 was not updated after hearing impairment identified |
| Director of Nursing | Director of Nursing | Stated care plan should have been updated after hearing impairment identified for Resident #207 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported Resident #160 refused hearing aid use and attempted to apply it |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Reported no follow-up on hearing aid issues for Resident #160 |
| Director of Housekeeping and Maintenance | Director of Housekeeping and Maintenance Departments | Oversaw housekeeping and maintenance, acknowledged environmental issues and plans for repair |
| Housekeeper #1 | Housekeeper | Described daily cleaning routines and challenges |
| Housekeeper #2 | Housekeeper | Reported cleaning routines and maintenance reporting process |
| Housekeeping Supervisor | Housekeeping Supervisor | Oversaw housekeeping staff and cleaning tasks |
| Administrator | Administrator | Discussed plans for environmental repairs and upgrades |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 5, 2022
Visit Reason
The inspection was conducted as a Recertification Survey from 06/27/22 to 07/05/22 to assess compliance with care standards, specifically focusing on residents' activities of daily living (ADL) assistance.
Findings
The facility failed to ensure that Resident #143 received necessary assistance with personal hygiene, specifically toenail care, despite documented care plans and podiatry consults. Multiple observations and interviews confirmed the resident had long uncut toenails over several days, and staff failed to arrange timely podiatry consultations.
Deficiencies (1)
Failure to provide care and assistance to perform activities of daily living for Resident #143, evidenced by long uncut toenails despite care plans and podiatry consults.
Report Facts
Residents Affected: 1
Inspection Report
Re-Inspection
Deficiencies: 6
Date: Sep 23, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations related to resident dignity, environment, social services, medication use, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity (e.g., resident wearing oversized, soiled sneakers without socks), lack of a homelike environment in resident rooms, inadequate medically-related social services, inappropriate use of psychotropic medications without proper diagnosis or non-pharmacological interventions, improper food storage temperatures and inadequate cleaning of food preparation equipment, and failure to maintain infection prevention and control practices such as hand hygiene by visiting eye doctor.
Deficiencies (6)
Resident observed wearing oversized, soiled, and tattered sneakers without socks, indicating failure to treat resident with dignity.
Resident rooms observed with bare white walls lacking decor, creating a colorless, dull environment.
Failure to provide medically-related social services to help resident achieve highest quality of life, specifically not assisting resident with obtaining new footwear and socks.
Resident prescribed psychotropic medications without appropriate diagnosis and without attempts at non-pharmacological interventions.
Potentially hazardous cold foods (sandwiches) were not maintained at proper temperature (above 41°F) and meat slicer equipment was not properly cleaned after use.
Consultant eye doctor did not properly clean overbed table or perform adequate hand hygiene prior to eye exam.
Report Facts
Deficiencies cited: 6
Temperature of sandwiches: 65.1
Temperature of sandwiches: 58.8
Temperature of sandwiches: 62.6
Temperature of sandwiches: 61.2
Temperature of sandwiches: 60.1
Temperature of sandwiches: 60.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Interviewed regarding resident's footwear and clothing needs. |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Interviewed regarding resident clothing needs and observations. |
| Social Worker | Social Worker | Interviewed regarding resident's personal fund account and clothing distribution system. |
| Administrator | Administrator | Interviewed regarding policy implementation and resident environment. |
| Current Psychiatrist | Psychiatrist | Interviewed regarding psychotropic medication use and resident behavior. |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding medication changes and resident behavior. |
| Primary Physician | Physician | Interviewed regarding resident admission, medication use, and behavior. |
| Dietary Aide #9 | Dietary Aide | Observed and interviewed regarding sandwich preparation and temperature monitoring. |
| Dietary Aide #10 | Dietary Aide | Observed cleaning meat slicer and sandwich preparation. |
| Dietary Supervisor #11 | Dietary Supervisor | Interviewed and observed regarding sandwich temperature monitoring and meat slicer cleaning. |
| Eye Doctor | Consultant Eye Doctor | Observed and interviewed regarding hand hygiene and equipment cleaning during eye exams. |
| Medical Director | Medical Director | Interviewed regarding psychiatric referrals and medication oversight. |
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