Cypress Grove Rehabilitation Center
CYPRESS GROVE REHABILITATION CENTER in NEWBURGH, IN — inspection on April 9, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
to be exemestane 25 milligrams (mg) (steroidal drug). On 4/8/26 at 1:21 P.M., Resident 2's clinical record was reviewed.
Diagnoses included, but were not limited to, malignant neoplasm of upper-inner quadrant of left female breast.
The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/5/26, indicated Resident 2 was cognitively intact and was independent for eating.
Physician orders included, but were not limited to: exemestane tablet 25 mg oral once a day; Start date 10/9/23 During an interview on 4/9/26 at 11:35 A.M., the Director of Nursing (DON) indicated Resident 2 did not have a self-administration of medications assessment. On 4/9/26 at 12:48 P.M., the Administrator provided a policy titled Self Administration of Medications, revised 1/2008, that indicated The nurse at the Community must also evaluate each resident who self-administers his or her medication by completing the Self-Administration of Medication Assessment form.
The nurse will approve each resident that self-administers medication to ensure safe and effective procedures are followed. 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)
155273 04/09/2026
Cypress Grove Rehabilitation Center 4255 Medwell Dr Newburgh, IN 47630
During an interview on 04/6/26 at 9:31 A.M., Resident 2 indicated the cooked food was sometimes cooked food was cold at times.4.
During an interview on 4/6/26 at 9:39 A.M., Resident 25 indicated the cooked food was sometimes cold. 5.
During an interview on 4/6/26 at 10:07 A.M., Resident 21 indicated the cooked food was cold and not always cooked thoroughly if they ate in their room. 6.
During a Resident Council meeting on 4/7/26 at 2:15 P.M., three anonymous residents indicated the food was not always warm if they ate in their room.
During an interview on 4/9/26 at 11:15 A.M, the Dietary Manager indicated the food must be served at an adequate temperature and with palatable taste, and that resident food preferences were accommodated. On 4/9/26 at 12:48 P.M., the Administrator provided a current Food Temperatures policy, revised 5/2025.
The policy indicated .all hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food.410 IAC (Indiana Administrative Code) 16.2-3.1-3(v)(1) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155273 04/09/2026
Cypress Grove Rehabilitation Center 4255 Medwell Dr Newburgh, IN 47630
(Resident 10) and 1 of 5 residents reviewed for falls (Resident 39).
Findings include:1. On 4/7/26 at
Alzheimer's disease and major depressive disorder.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/30/26, indicated Resident 10 had severe cognitive impairment and received an antidepressant during the 7-day lookback period.The clinical record lacked an active physician order for an antidepressant medication between 3/23/26 and 3/30/26.
The March 2026 electronic Medication Administration Record (eMAR) lacked documentation that an antidepressant medication was administered to Resident 10 between 3/23/26 and 3/30/26.2. On 4/7/26 at 10:57 A.M., Resident 39's clinical record was reviewed.
Diagnoses included, but were not limited to, dementia.The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/30/26, indicated Resident 39 had severe cognitive impairment and had one fall with no injury since the prior assessment on 12/29/25.The clinical record lacked documentation to indicate Resident 39 fell between 12/30/25 and 3/30/26.
During an interview on 4/9/26 at 10:50 A.M., the Administrator indicated Resident 39 did not fall between 12/30/25 and 3/30/26.
During an interview on 4/9/26 at 11:22 A.M., the Regional Clinical Nurse indicated that the MDS Assessments dated 3/30/26 for Resident 10 and Resident 39 were both wrong.
The MDS Coordinator looked at the wrong dates for the fall and antidepressant.
During an interview on 4/9/26 at 12:48 P.M., the Administrator indicated that the facility followed Resident Assessment Instrument (RAI) guidelines to code MDS Assessments.
155273 04/09/2026
Cypress Grove Rehabilitation Center 4255 Medwell Dr Newburgh, IN 47630
unattended, he had no way to notify staff when he was ready to go back inside, stated he was not offered sunscreen, and was ready to go back inside. On 4/8/26 at 2:10 P.M., Resident 57's clinical record was reviewed.
Diagnoses included, but were not limited to, paraplegia.
The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/16/26, indicated Resident 57 was moderately cognitively impaired, was dependent on staff (staff does all of the work) for transfers, and utilized a manual wheelchair for mobility.
The current care plan included, but was not limited to: Resident likes to go outside building in unsecured area.
Resident is not an elopement risk, when outside resident does not leave the facility property, resident has BIMS of 13 and has been educated on notifying staff when he is out of building and to stay on sidewalk and not in parking lot; Start date 8/15/18Interventions included, but were not limited to:Encourage resident to have drink of choice when outside, supply sunscreen to resident when outside and assist with applying when appropriate, offer assistance in/out doors.
During an interview on 4/8/26 at 1:56 P.M., Registered Nurse (RN) 5 indicated there was no monitoring system or set time periods to check on Resident 57 while he was outside unattended but staff often told the resident a time limit he could be outside. RN 5 indicated Resident 57 was not wearing sunscreen because he often refused it when it was previously offered. Resident 57's physician orders lacked an order for sunscreen available to offer to the resident. On 4/9/26 at 12:48 P.M., the Administrator provided a policy titled Comprehensive Care Plan, revised 10/2025, that indicated Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each OBRA MDS assessment. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)410 IAC 16.2-3.1-35(b)(2)
155273 04/09/2026
Cypress Grove Rehabilitation Center 4255 Medwell Dr Newburgh, IN 47630
include: 1. On 4/9/26 at 10:24 A.M., Resident 25's clinical record was reviewed.
Diagnoses included,
Assessment, dated 1/13/26, indicated Resident 25 was cognitively intact and required partial assistance from staff (staff does half of the work) for bathing. A grievance form, dated 10/29/25, indicated Resident 25 was not getting her showers and was not getting her hair washed.
The form indicated staff were educated on preference of shower not a complete bed bath. A shower schedule, updated 4/1/26, indicated Resident 25's shower dates were Tuesday and Friday.
Shower documentation reviewed in the electronic medical record and paper shower documents indicated Resident 25 had not received a shower on the following scheduled days from 3/9/26-4/9/26: 3/10/263/27/263/31/26 2. On 4/9/26 at 8:49 A.M., Resident 18's clinical record was reviewed.
Diagnoses included, but were not limited to, dementia.
The most recent admission Minimum Data Set (MDS) Assessment, dated 3/18/26, indicated Resident 18 was cognitively intact and required supervision from staff during bathing. A shower schedule, updated 4/1/26, indicated Resident 18's shower dates were Wednesday and Saturday.
Shower documentation reviewed in the electronic medical record and paper shower documents indicated Resident 18 had not received a shower on the following scheduled days from 3/11/26-4/9/26:3/14/263/18/263/25/26 Shower documentation indicated Resident 18 refused a shower on 4/8/26 due to the shower being offered outside of his preferred shower time. On 4/19/26 at 12:48 P.M., the Administrator provided a policy titled Residents Rights, revised 7/2023, that indicated All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)
155273 04/09/2026
Cypress Grove Rehabilitation Center 4255 Medwell Dr Newburgh, IN 47630
gave Resident G calcitonin in the left nostril two out of seven administrations when the order was for
administering calcitonin spray to Resident G as ordered, but were not documenting it correctly.
On 4/9/26 at 1:09 P.M., the Administrator provided a current Documentation policy, revised 8/2025.
The policy indicated for staff to accurately document in an organized manner all information related to the resident in the medical record .
Weekly Skin and vital sign assessment observation (All new skin areas must be reported to the wound nurse with new skin event completed) .
Wound management entries for all ulcers and for non-ulcer areas that are not healing or showing signs of improvement.
This citation relates to Intake 2803351. 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1) 410 IAC 16.2-3.1-50(a)(2)
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NEWBURGH, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CYPRESS GROVE REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.