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Cypress Glen East Nursing & Rehabilitation

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About Cypress Glen East Nursing & Rehabilitation

General Information

Legal Business NamePm Management - Golden Triangle Nc Iv LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareNovember 13, 2003 (14 years)
Capacity128
Residents72
Percent Occupied56%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Cypress Glen East Nursing & Rehabilitation

Cypress Glen East Nursing & Rehabilitation
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

December 14, 2016 - 6 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionHire a qualified dietician.
FManyPotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FManyPotential for HarmHealth InspectionKeep clinical record information safe.
FManyPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FManyPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
FManyPotential for HarmHealth InspectionTry to resolve each resident's complaints quickly.
FManyPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
ESomePotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
ESomePotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmHealth InspectionProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
ESomePotential for HarmHealth InspectionListen to the resident groups and act on their complaints and suggestions that affect resident care and life.
CManyPotential for Minimal HarmHealth InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
CManyPotential for Minimal HarmHealth InspectionHire a qualified full-time social worker in a facility with more than 120 beds.

September 7, 2016 - 10 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
FManyPotential for HarmComplaintAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

May 25, 2016 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaint1) 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.
ESomePotential for HarmComplaintDevelop 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.
DFewPotential for HarmComplaintMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

May 9, 2016 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintTry to resolve each resident's complaints quickly.

January 6, 2016 - 18 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
FManyPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
FManyPotential for HarmHealth InspectionMake sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionProvide food in a way that meets a resident's needs.
ESomePotential for HarmHealth InspectionReasonably accommodate the needs and preferences of each resident.
ESomePotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

June 24, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintTry to resolve each resident's complaints quickly.

May 4, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintDevelop 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.
ESomePotential for HarmComplaint1) 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.

February 11, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
CManyPotential for Minimal HarmHealth InspectionHave a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.
CManyPotential for Minimal HarmHealth InspectionProvide residents with private access to a telephone.
CManyPotential for Minimal HarmHealth InspectionGive residents a notice of rights, rules, services and charges.
DFewPotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Cypress Glen East Nursing & Rehabilitation require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 45min
2hr 25min
ReportedExpected
CNA

40min
ReportedExpected
LPN
30min
1hr 20min
ReportedExpected
RN
3hr 15min
4hr 25min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

96.2%
100.0%
100.0%
100.0%
91.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
98.4%
100.0%
100.0%
100.0%
89.8%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
51.7%
47.6%
50.0%
53.1%
48.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of low risk long-stay residents who lose control of their bowels or bladder
35.3%
26.4%
39.3%
31.5%
27.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antianxiety or hypnotic medication
21.8%
15.4%
22.7%
12.1%
20.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose ability to move independently worsened
26.2%
24.1%
19.0%
19.4%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antipsychotic medication
8.2%
14.0%
13.0%
3.7%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose need for help with daily activities has increased
2.1%
2.0%
4.0%
2.3%
7.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who self-report moderate to severe pain
13.1%
18.6%
13.8%
6.2%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who lose too much weight
2.2%
2.4%
0.0%
0.0%
6.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of high risk long-stay residents with pressure ulcers
0.0%
0.0%
0.0%
0.0%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who have depressive symptoms
0.0%
5.1%
10.8%
1.5%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a urinary tract infection
1.6%
5.1%
3.1%
6.2%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents experiencing one or more falls with major injury
3.9%
3.2%
3.0%
0.0%
2.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

96.3%
98.3%
96.4%
96.6%
74.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
94.5%
94.9%
94.9%
94.9%
71.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
55.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
5.9%
2.9%
10.3%
9.3%
14.2%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who self-report moderate to severe pain
5.1%
2.7%
0.0%
0.0%
3.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who newly received an antipsychotic medication
2.6%
0.0%
1.4%
1.3%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents with pressure ulcers that are new or worsened