Inspection Reports for Cypress Garden Center for Nursing & Rehabilitation

One isolated Level 2 deficiency for free from abuse and neglect, corrected as of March 23, 2025.

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.

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.

Multiple isolated and pattern Level 2 deficiencies in quality of care and life safety code, all corrected by November 22, 2024.

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.

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.

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.

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.