Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to obtain laboratory services to meet the needs of Resident #31, specifically for ordered lipid panel and thyroid panel tests.
Complaint Details
The complaint investigation found that the facility did not follow through on a pharmacist's suggestion for lipid and thyroid panel labs for Resident #31. The physician agreed to the order but it was never placed or completed. Interviews with the Director of Nursing, MDS nurse, and Medical Records staff revealed confusion and breakdown in the ordering process. The physician did not return calls regarding the order.
Findings
The facility failed to ensure Resident #31 received ordered lab tests for lipid and thyroid panels, which were necessary to monitor medication levels for atorvastatin and levothyroxine. Interviews revealed a breakdown in the ordering process, resulting in the labs never being ordered or completed, posing a risk of adverse effects and decline in health.
Deficiencies (1)
Failure to provide timely, quality laboratory services/tests to meet the needs of residents, specifically Resident #31 not receiving ordered lipid and thyroid panel lab tests.
Report Facts
Residents reviewed for laboratory services: 5
Resident #31's BIMS score: 14
Date of pharmacist communication: Sep 4, 2024
Date physician signed agreement: Sep 23, 2024
Date of physician orders review: Jan 7, 2025
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 2
Date: Jun 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents' environment was free from accident hazards and that residents received adequate supervision and assistance to prevent accidents, specifically related to a barricaded exit door on Hall A.
Complaint Details
The complaint investigation found an immediate jeopardy condition on 6/4/2024 due to a barricaded exit door on Hall A that prevented safe evacuation of 8 residents. The immediate jeopardy was removed on 6/5/2024 after removal of the barricade, but the facility remained out of compliance at a lower severity level pending evaluation of corrective system effectiveness.
Findings
The facility failed to ensure 8 residents on Hall A could evacuate in an emergency due to plywood bolted to the exterior exit door, creating a dead-end corridor. This condition posed immediate jeopardy to resident health and safety. The plywood barricade was removed promptly, and corrective actions including staff education and exit monitoring were implemented.
Deficiencies (2)
Facility failed to ensure 8 residents could evacuate due to plywood bolted down to the exterior door barricading the exit on Hall A.
Facility failed to ensure 8 residents on Hall A had two exits available due to the dead-end corridor created by the barricaded door.
Report Facts
Residents affected: 8
Residents reviewed: 59
Date of immediate jeopardy identification: Jun 4, 2024
Date immediate jeopardy removed: Jun 5, 2024
Temperature reading: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Oversaw project installing plywood barricade; unaware it created dead-end corridor | |
| Administrator | Interviewed regarding barricade and evacuation plans; provided education on exit egress | |
| RN B | Registered Nurse | Reported air conditioning issues and observed plywood barricade |
| CNA B | Certified Nursing Assistant | Reported air conditioning issues and knowledge of barricaded exit door |
| DON | Director of Nursing | Interviewed about barricade and evacuation procedures; unaware of dead-end corridor |
| Medical Records Coordinator | Noted plywood barricade and portable air conditioning installation | |
| MDS Nurse | In-serviced on door egress; unaware of barricade on Hall A | |
| LVN B | Licensed Vocational Nurse | Observed installation of plywood barricade; aware of evacuation risks |
Inspection Report
Routine
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan implementation, specifically focusing on fall risk interventions for Resident #1, following multiple previous falls and the initiation of new fall prevention measures.
Findings
The facility failed to implement a comprehensive person-centered care plan intervention for Resident #1 to address fall risk, including the absence of a fall mat at the bedside and the resident's bed not being in the lowest position as required. Observations and interviews confirmed these interventions were not in place despite being initiated in the care plan.
Deficiencies (1)
Failure to implement a comprehensive care plan intervention for Resident #1 addressing fall risk, including lack of fall mat at bedside and bed not in lowest position.
Report Facts
Fall risk score: 17
BIMS score: 13
Residents reviewed for care plans: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Interviewed about awareness of fall mat intervention for Resident #1 | |
| CNA B | Observed Resident #1's bed position and lack of fall mat; commented on responsibility for interventions | |
| LVN A | Licensed Vocational Nurse | Interviewed about fall mat intervention and staff responsibilities |
| DON | Director of Nursing | Interviewed about fall interventions, staff training, and responsibility for ensuring interventions |
| Central Supply | Responsible for supplies like fall mats; interviewed about notification of fall mat need | |
| Admin | Administrator | Interviewed about staff responsibilities and communication regarding fall interventions |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding comprehensive, accurate, and standardized assessments of residents' functional capacity.
Findings
The facility failed to conduct accurate and comprehensive assessments for 3 of 16 residents reviewed, specifically failing to document fall histories and oral/dental status accurately, which could place residents at risk of inadequate care.
Deficiencies (3)
Facility failed to ensure assessments accurately reflected Residents #5 and #41's falls.
Facility failed to ensure Resident #5 was accurately assessed for her oral cavity.
Facility failed to ensure Resident #47 was accurately assessed for her falls and oral dental health.
Report Facts
Residents reviewed for comprehensive assessment: 16
Residents affected: 3
Accident and incident history period: 6
Fall dates for Resident #47: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed on 11/30/23 regarding assessment inaccuracies and facility policies |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and food service safety at Cypress Woods Care Center.
Findings
The facility failed to conduct accurate and comprehensive assessments for several residents, resulting in incomplete fall and oral health documentation. Additionally, care plans were not updated to reflect current resident needs, and food service practices did not meet professional standards, including improper food labeling, expired food storage, unclean kitchen equipment, and malfunctioning dishwashing machine temperature gauges.
Deficiencies (3)
Failed to conduct initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity for 3 of 16 residents.
Failed to develop a comprehensive person-centered care plan describing services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 15 residents.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including unclean utensils, unlabeled and undated food items, expired food products, and malfunctioning dishwashing machine temperature gauge.
Report Facts
Residents reviewed for comprehensive assessment: 16
Residents reviewed for care plan revision: 15
Falls recorded for Resident #5: 1
Falls recorded for Resident #47: 3
Dishwashing machine temperature: 120
PPM reading of dishwasher sanitizer: 200
Expired food items: 3
Expired food items: 3
Expired food items: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding inaccurate assessments and care plan revisions | |
| DON | Director of Nursing | Interviewed about care plan responsibilities |
| DM | Dietary Manager | Interviewed about food labeling, expired food removal, and kitchen sanitation |
| Facility Administrator | Administrator | Interviewed about oven hood cleaning schedule and contractor delays |
| [NAME] B | Interviewed about dishwasher water testing | |
| [NAME] C | Interviewed about dishwasher temperature gauge malfunction | |
| Cooperate Manager | Interviewed about dishwasher temperature impact on sanitization |
Inspection Report
Routine
Deficiencies: 13
Date: Sep 23, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments, baseline and comprehensive care plans, catheter care, respiratory care, dietary services, infection control, and safety of bed rails.
Findings
The facility failed to accurately code diagnoses on MDS assessments for several residents, develop and implement baseline and comprehensive care plans reflecting residents' needs, maintain proper catheter care and infection control practices, ensure oxygen therapy equipment was properly maintained, provide therapeutic diets as ordered, maintain medical records with complete physician orders, and conduct regular inspections and assessments of bed rails.
Deficiencies (13)
Facility failed to have accurate MDS assessments for 3 residents by not coding pacemakers and heart failure diagnoses.
Failed to develop and implement baseline care plans addressing immediate needs for 3 residents, including cardiac issues and code status.
Failed to develop and implement comprehensive person-centered care plans reflecting residents' needs including bed rails, pacemaker, and cardiac status for 3 residents.
Failed to review and revise comprehensive care plans after assessments to reflect changes in code status for 4 residents.
CNA did not clean indwelling urinary catheter tubing and raised urinary drainage bag above bladder level during care for Resident #46.
Failed to provide safe and appropriate respiratory care; oxygen tubing not dated and masks/cannulas not bagged for residents on oxygen therapy.
Failed to assess and obtain informed consent for use of bed rails for Resident #35.
Cook diluted pureed egg salad and macaroni salad with water, reducing nutritive value of food served.
Failed to provide therapeutic diet as ordered; Resident #48 was served regular pinto beans instead of pureed diet.
Cook used facility phone multiple times during meal service without washing hands afterwards.
Failed to maintain complete and accurate medical records; Resident #21 lacked physician order for code status and Resident #50 lacked physician order for pacemaker.
CNA and LVN did not sanitize hands between glove changes during catheter and wound care for Resident #46.
Failed to conduct inspection and assessment of bed frames, mattresses, and bed rails for Resident #21.
Report Facts
Residents reviewed for accurate MDS assessments: 24
Residents reviewed for baseline care plans: 3
Residents reviewed for comprehensive care plans: 8
Residents reviewed for comprehensive care plan revision: 20
Residents reviewed for catheter care: 2
Residents reviewed for oxygen therapy: 6
Residents reviewed for therapeutic diets: 20
Residents reviewed for code status: 24
Residents reviewed for bed rails: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in catheter care and infection control deficiencies for Resident #46 | |
| LVN B | Named in wound care and infection control deficiencies for Resident #46 | |
| MDS Coordinator | Named in multiple interviews regarding MDS assessments, care plan revisions, and coding issues | |
| DON | Director of Nursing | Named in multiple interviews regarding care plan and coding deficiencies |
| Cook D | Named in food preparation and hand hygiene deficiencies | |
| Food Service Supervisor | Named in food preparation and hand hygiene deficiencies | |
| DCO | Director of Clinical Operations | Named in bed rail and oxygen therapy observations |
| Maintenance Director | Named in bed rail inspection deficiency | |
| LVN C | Named in therapeutic diet observation | |
| ST | Speech Therapist | Named in therapeutic diet interview |
| SW Coordinator | Named in care plan revision interviews |
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