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🔎 Cypress Woods Care Center

Inspection Results


Inspection Overview

Cypress Woods Care Center has been cited for a total of 39 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2025-01-08
Correction Date: 2025-01-24
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: K

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-06-07
Correction Date: 2024-06-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-05-09
Correction Date: 2024-05-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-11-30
Correction Date: 2023-12-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-11-30
Correction Date: 2023-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2023-11-30
Correction Date: 2023-12-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Survey Date: 2022-10-27
Correction Date: 2022-11-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2022-10-27
Correction Date: 2022-11-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-10-27
Correction Date: 2022-11-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-10-27
Correction Date: 2022-11-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-09-23
Correction Date: 2022-11-04
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Survey Date: 2022-09-23
Correction Date: 2022-09-30
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-12-14
Correction Date: 2021-12-15
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-07-29
Correction Date: 2021-08-07
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Survey Date: 2021-07-29
Correction Date: 2021-08-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-07-29
Correction Date: 2021-08-07
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2021-06-17
Correction Date: 2021-07-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-06-02
Correction Date: 2021-07-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2020-11-23
Correction Date: 2020-12-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-11-23
Correction Date: 2020-12-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2019-08-02
Correction Date: 2019-09-15
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**