Inspection Reports for The Cypress of Charlotte
3442 Cypress Club Dr, Charlotte, NC 28210, NC, 28210
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a cognitively impaired resident exited the facility unsupervised through a malfunctioning wanderguard alarm system, resulting in injury.
Complaint Details
The complaint investigation was substantiated. Immediate jeopardy began on 09/06/25 when Resident #1 exited the facility unsupervised and without staff knowledge. Immediate jeopardy was removed on 09/12/25 after the facility implemented corrective measures. The deficient practice affected 1 of 3 residents reviewed for supervision to prevent accidents.
Findings
The facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping through a propped open door with a malfunctioning wanderguard alarm system. The resident was found injured outside the facility. Immediate jeopardy was identified and later removed after corrective actions were implemented, but the facility remained out of compliance at a lower severity level.
Deficiencies (1)
Failure to ensure a nursing home area was free from accident hazards and to provide adequate supervision to prevent accidents, resulting in immediate jeopardy to resident health or safety.
Report Facts
Distance resident found from facility: 870
Speed limit: 35
Blood pressure: 193
Pulse: 97
Oxygen saturation level: 99
Temperature: 97.9
Elopement risk score: 5
Elopement risk score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #4 | Nurse | Completed admission assessment and elopement evaluation risk assessment for Resident #1. |
| Nurse #5 | Nurse | Completed elopement risk evaluation for Resident #1. |
| Nurse #2 | Nurse | Documented Resident #1's elopement attempts and wanderguard bracelet incidents. |
| Nurse #1 | Nurse | Notified staff of Resident #1's elopement incident on 09/06/25 and provided medical information to EMS. |
| Nurse #3 | Nurse | Observed and redirected Resident #1 during exit attempts. |
| NA #1 | Nursing Assistant | Responsible for Resident #1 during 09/06/25 shift and provided observations regarding the incident. |
| NA #2 | Nursing Assistant | Worked on adjoining hallway and provided observations on 09/06/25. |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #1's admission and supervision. |
| Assistant Director of Nursing | Assistant Director of Nursing | Assisted with incident response and provided interview about the event. |
| Dietary Manager | Dietary Manager | Propped open the conference room doors leading to the exit used by Resident #1. |
| Facility Maintenance Director | Facility Maintenance Director | Tested wanderguard bracelets and confirmed alarm system malfunction. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to administer a prescribed probiotic to Resident #7, who was receiving antibiotics and at risk for yeast infections.
Complaint Details
The complaint investigation found that Resident #7 was prescribed a probiotic to prevent yeast infection while on antibiotics, but the probiotic was not administered as ordered. The resident developed a yeast infection, and unused probiotic capsules were returned unopened to the pharmacy. The Responsible Party and staff interviews revealed confusion about the source and administration of the probiotic.
Findings
The facility failed to administer the probiotic ordered for Resident #7 despite documentation indicating administration. Interviews revealed discrepancies between medication administration records and returned unused medication, with the resident developing a yeast infection treated with vaginal cream.
Deficiencies (1)
Failure to administer a probiotic ordered for Resident #7 to prevent yeast infection during antibiotic treatment.
Report Facts
Medication order quantity: 6
Medication returned: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Interviewed regarding probiotic administration and familiarity with Resident #7 | |
| Nurse #2 | Documented probiotic administration but was not reachable for interview | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about discrepancies in medication administration records and unused medication |
| Hospice Nurse | Interviewed about probiotic order and treatment of yeast infection | |
| Pharmacist | Interviewed about medication orders and returned probiotic capsules |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, advanced directives, medication administration, infection control, care planning, and safety measures.
Findings
The facility was found deficient in multiple areas including failure to ensure proper signatures on advanced directive forms, failure to provide required Medicare notices, lack of written consent for room cameras, inaccurate resident assessments, incomplete care plans, unsafe use of mechanical lifts, unsecured medication carts, poor food storage practices, and inadequate infection prevention and antibiotic stewardship programs.
Deficiencies (12)
Failure to ensure the resident's Medical Order for Scope of Treatment (MOST) form was signed by the resident or resident representative.
Failure to provide a Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services.
Failure to maintain privacy during care and failure to obtain written consent for use of cameras in residents' rooms.
Failure to complete and transmit discharge and death Minimum Data Set (MDS) assessments within required timeframes.
Failure to accurately code Minimum Data Set (MDS) for functional limitations and anticoagulant medication use.
Failure to develop and implement person-centered care plans with measurable goals and interventions for anticoagulants, psychotropic medications, and wander/elopement alarms.
Failure to secure mechanical lift and wheelchair during resident transfer.
Failure to secure resident medications in unattended medication cart.
Failure to maintain clean ice cream freezer, label and date perishable food items in walk-in cooler, reach-in refrigerator, and seal frozen items in walk-in freezer.
Failure to implement an infection prevention and control program including surveillance, policy review, and staff training.
Failure to implement an antibiotic stewardship program with proper documentation and monitoring of antibiotic use.
Failure to provide stop dates for psychotropic medications prescribed as needed.
Report Facts
Residents reviewed for Advanced Directives: 2
Residents reviewed for beneficiary protection notification: 3
Residents reviewed for privacy: 2
Residents reviewed for resident assessments: 3
Residents reviewed for accuracy of assessments: 4
Residents reviewed for development and implementation of care plan: 5
Residents reviewed for accidents: 2
Medication carts observed: 2
Monthly surveillance data reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Interviewed regarding MOST form signature, camera usage, and medication monitoring | |
| Nurse #2 | Observed leaving medication cart unlocked | |
| Nurse #3 | Unable to locate infection control manual at nurse's station | |
| Director of Nursing | DON | Interviewed regarding advanced directives, camera usage, care plans, mechanical lift education, medication cart security, infection control, and antibiotic stewardship |
| Social Worker | SW | Interviewed regarding advanced directives and Medicare notices |
| Administrator | Interviewed regarding advanced directives, Medicare notices, camera usage, care plans, mechanical lift education, medication cart security, infection control, and antibiotic stewardship | |
| Nurse Aide #1 | NA #1 | Interviewed regarding camera usage and mechanical lift use |
| Nurse Aide #2 | NA #2 | Interviewed regarding mechanical lift use |
| Nurse Aide #3 | NA #3 | Interviewed regarding camera usage and resident care |
| Pharmacist | Interviewed regarding psychotropic medication stop dates | |
| Staff Development Coordinator | SDC | Interviewed regarding staff education on mechanical lifts |
| Infection Preventionist | IP | Interviewed regarding infection control program and antibiotic stewardship |
| Medical Director | Interviewed regarding infection control and psychotropic medication monitoring |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 18, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at The Stewart Health Center.
Findings
No health deficiencies were found during the inspection.
Viewing
Loading inspection reports...
