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Deficiency Records for Cypress Ridge Care Center
A list of the most recent deficiencies for Cypress Ridge Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Cypress Ridge Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-07-09 | 2024-07-29 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-06-04 | 2024-06-27 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-05-21 | 2024-06-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-21 | 2024-06-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-02 | 2024-05-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-02 | 2024-05-24 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-01 | 2024-02-29 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-01-25 | 2024-02-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-25 | 2024-02-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-25 | 2024-02-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-25 | 2024-02-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-19 | 2024-01-15 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-19 | 2024-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-08 | 2023-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-03 | 2023-10-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-08-23 | 2023-09-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-23 | 2023-09-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-10 | 2023-08-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-10 | 2023-08-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-10 | 2023-08-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-21 | 2023-04-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-22 | 2023-03-03 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-09 | 2022-08-31 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-25 | 2021-07-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-21 | 2021-06-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-21 | 2021-06-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-21 | 2021-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-21 | 2021-06-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-21 | 2021-06-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-21 | 2021-06-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-10 | 2019-10-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-07-24 | 2019-08-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-24 | 2019-08-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-24 | 2019-08-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-24 | 2019-08-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-24 | 2019-08-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-24 | 2019-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-24 | 2019-08-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-07-24 | 2019-08-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-24 | 2019-08-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-24 | 2019-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-24 | 2019-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-24 | 2019-08-13 | N |
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