CYPRESS GLEN

Nursing Home Inspector

7200 NINTH AVE
PORT ARTHUR, TX 77642
Jefferson County
Phone: 409-729-8701
Provider Number: 675839
Last Inspection: 06/07/2017

About the Nursing Home

Number of Beds: 188
Number of Residents: 111
Beds Available: 77
Percent Occupancy: 59%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

37

Facility
29

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

37

2017
9

2016
44

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/7/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Minimal 5 6/30/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 7/7/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Widespread : Minimal 5 7/7/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Widespread : Minimal 5 7/7/2017
 
Failed To: Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Pattern : Minimal 4 6/30/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 6/30/2017
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Widespread : Minimal 5 6/19/2017
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Widespread : Minimal 5 7/7/2017
 

6/29/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 8/3/2016
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Widespread : Minimal 5 8/4/2016
 

7/16/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Widespread : Minimal 5 8/24/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Actual 5 8/24/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 8/24/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 8/24/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Actual 5 8/24/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 8/24/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 8/24/2015
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 8/24/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 8/24/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 8/24/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/19/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 7/21/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 7/21/2017
 

9/29/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 10/24/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 10/24/2015
 

5/20/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 6/10/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 6/10/2015
 

3/9/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Isolated : Minimal 3 3/31/2015
 

12/15/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Minimal 4 1/16/2015
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 1/16/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 1/16/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 111 80.87 75.11
Registered Nurses 0.32 0.44 0.59
Licensed Practical / Vocational Nurses 1.54 1.06 0.94
Certified Nursing Assistants 2.18 2.13 2.20
Total Staff Hours 4.03 3.63 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 7 4 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 98 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 98 92
of long-stay residents experiencing one or more falls with major injury 5 2 3
of long-stay residents who have depressive symptoms 2 1 3
of long-stay residents who lose too much weight 5 4 5
of long-stay residents who received an antianxiety or hypnotic medication 24 29 26
of long-stay residents who received an antipsychotic medication 24 17 17
of long-stay residents who self-report moderate to severe pain 1 1 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 17 16 20
of long-stay residents whose need for help with daily activities has increased 11 18 18
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 1 2 3
of low risk long-stay residents who lose control of their bowels or bladder 36 42 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 77 91 77
of short-stay residents who had an outpatient emergency department visit 14 15 13
of short-stay residents who made improvements in function 53 57 59
of short-stay residents who newly received an antipsychotic medication 1 1 2
of short-stay residents who self-report moderate to severe pain 6 7 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 76 84 74
of short-stay residents who were rehospitalized after a nursing home admission 24 29 23
of short-stay residents who were successfully discharged to the community 30 36 46
of short-stay residents with pressure ulcers that are new or worsened 0 0 0