Villa Toscana At Cypress Woods

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents' information and if a computer screen is open and information is exposed that can cause a privacy breach of residents' personal and medical information. Record review of facility's staff educational course script, undated, revealed that HIPAA 101 - protecting private health information is any data that can identify a patient such as names, addresses, birth dates, medical record numbers, and other personal details. Digital best practice interacts with email and devices using strict security measures that protect private health information at every step: (2). Lock or log off devices when stepping away.Record review of staff in-services, dated 11/13/2025, revealed 12 nursing staff were in serviced on nurse/med aide cart protocol Carts are to be locked, and screens are to be closed when not in front of cart. No earlier dated staff in-services were available for review. Record review of HR - Personnel Handbook, dated 9/20/2019, revealed information on Confidentiality/HIPAA Regulation: The Privacy Policy reflects practices that have been adopted by the facility to protect patients' privacy and security in relation to their Protected Health Information as defined under HIPAA regulation. It is the duty and responsibility of each staff person associated with this facility to be fully familiar with Privacy Policy and to comply with the requirements detailed within it. The Privacy Policy is available to all facility employees for review at any time and may be obtained by requesting a copy from the Privacy Officer.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Toscana at Cypress Woods

15015 Cypress Woods Medical Dr Houston, TX 77014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident, and risks are entrapment, and sliding between the bed rails. The DON said they do not have to have a doctor's order for the bed rails. The DON said there had been some bruises and skin tears due to

the bed rails. She said she did not remember what residents did or when the residents sustained the bruises and skin tears. She said she was not sure how long ago that was. The DON said she did not know of any residents who had a decline due to the bedrails being used The DON said the assessment had the reason the bed rails were being used on each resident. During an interview on 11/13/2025 at 5:55p.m. with LVN C revealed he had not been trained on restraints. He said that the policy on restraints was that the facility had to have a doctor's order to use the bed rails. He said the family requests the doctor order and

they do an assessment to see if the resident qualify to use the bedrails. He said he was unsure if he had been trained on the bed rails at the facility. He said he thinks he just had on the job training. He said the bed rails are up for some of the residents because the bed rails decrease the risk of injury. He said he is unsure how long the bed rails stay up. An observation was conducted on 11/13/2025 at 8:45PM which revealed 28 residents including Resident #2, Resident #3 and Resident #4 had bed rails up and in use on the residents beds while the residents were sleeping. An interview was conducted on 11/14/2025 at 10:26 AM. with CNA

A who stated the benefits of bed rails are that they could prevent residents from falling out of bed at night.

An interview was conducted on 11/14/2025 at 10:26AM with CNA B who revealed that bed rails could cause residents who are cognitively impaired to feel trapped in bed. An interview was conducted on 11/14/2025 at 10:41AM with RN B who stated bedrails can be restraints and the facility should have doctor's order to have them installed. RN B stated that bed rails can hurt residents if they try to climb out of bed. An interview was conducted on 11/14/2025 at 11:57AM the NP stated that all beds at the facility should have bed rails on them. The NP stated that he had not assessed residents for bed rails when at the facility, but the facility does not need a doctor order for bed rails. The NP stated he does not know how many residents have bed rails on the beds. The NP stated the risk of using bed rails is that they could be perceived as restraints. The NP stated that whenever a patient had bed rails all around the bed the resident would be locked in, resulting in the resident not being able to get out of bed, which would be considered a restraint. The NP stated he is not aware of any residents being injured while using bedrails. An interview was conducted on 11/14/2025 at 1:00PM with the ADM. The ADM stated that the facility is a restraint reduction facility, but they use bed rails. The ADM stated that residents need to have assessments done for bed rails. He stated that the facility does not use bed rails, they use assist bars. Record review of policy titled Bed Rails not dated revealed the following information: The facility will utilize bed rails for those residents that use them for bed mobility. The facility will attempt to use appropriate alternative prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use and maintenance of bed rails including but not limited to the following elements: Assess the resident for risk of entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Prior to using a bed rail, the resident will be assessed to ensure the proper rail is utilized for the resident's need. The resident and/or resident representative will provide consent for the use of rails prior to installation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Toscana at Cypress Woods

15015 Cypress Woods Medical Dr Houston, TX 77014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

them were digging into her skin. Her toenail on big toe?was thick and brittle. Attempted interview with Resident #6 on 11/14/2025 at 9:17a.m., revealed she was not interviewable.During an Interview with CNA C on 11/13/2025 at 3:38p.m., she stated that the staff in the secure care unit was not touching residents' toenails. She said the podiatrist would come to the unit and provide toenail care. She said the staff reported to the nurse if any resident needed foot care. She said not trimming resident's nails can cause discomfort, pain, and infection. She did not know why Resident #5 and Resident #6's toenails had not been cut or referred to the podiatrist. During an Interview with the DON on 11/13/2025 at 5:28p.m., she stated the podiatrist saw the residents every 62 to 90 days. She said staff were to report if a resident had long toenails to a nurse. She said not cutting long toenails could cause the resident to have an ingrown toenail and could be painful to treat. She said she did not know why Resident #5 and Resident #6 did not have their toenails cut by the podiatrist. During an interview with the SW on 11/14/25 at 12:02 p.m., he stated that he orchestrates the podiatry clinics for the facility. He said the facility just hired a new podiatry group. He said

the new podiatry group had been to the facility twice. He said that he sends all required residents' information to the podiatrist. He said then the podiatrist would come to the facility and provides toenail care to the residents on the list. He said the last time the new podiatrist was at the facility was on October 23rd.

He said staff were expected to provide residents who were not diabetic toenail care. He said staff should do toenail care when the resident is given a shower. He said if staff did not provide toenail care to the residents

it could cause the resident pain and potentially infection. He did not know why staff had not cut Resident #5 and Resident #6's toenails. During an interview with the ADM on 11/14/2025 at 1:00p.m, he stated residents' toenail care was important because if staff let them get too long it could cause discomfort, injuries, and scratching. He also said many residents are nonverbal, so it was the facility's responsibility to do a head-to-toe assessment and refer them to physicians. He did not know who was supposed to do residents' toenails. He said he did not know why Resident #5 and Resident #6 did not have nail care.

Record review of ADL Nail Care Policy dated 3/10/2000 revealed Nail management is the regular care of

the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Nails can become thinner and more brittle

in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency. Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions. The resident will be free from infection. Should be performed according to the resident centered plan of care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Toscana at Cypress Woods

15015 Cypress Woods Medical Dr Houston, TX 77014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

monitors and so does the pharmacist. She said they monitor by doing cart checks. She said she did not know why there were loose pills on the medication carts. An interview was attempted on 11/14/2025 at 11:45AM with RN A. An interview was attempted on 11/14/2025 at 11:48AM with the pharmacist of the hospice company that provided the medications to RN A. An interview was conducted on 11/14/2025 at 1:00PM with the ADM who reported he had worked at the facility for 11 months. The ADM stated the DON, ADON and nursing staff are responsible for MC audits. The ADM stated that if there were medications at

the bottom of the MC, then there could be possibility that the resident did not receive the medication. The ADM stated that the policy for receiving medication is that the staff should not allow medications into the facility unless they have seen it, counted it, and signed off for it. The ADM stated if staff members signed for medication, and the medication could no longer be found, it could mean the residents did not receive it. The ADM stated that during the investigation, it was determined that the RN that signed off on the medication delivery passed her UA testing and had her own prescription for benzodiazepines. The ADM stated the RN had ultimately been suspended pending investigation. Record review of investigation record revealed that RN A had signed off on an unknown prescription delivery with Rx #327042 on 06/03/2025. Record review of a signed handwritten letter dated 06/04/2025, revealed RN A had received medications for the resident

on 06/03/2025 at approximately 7:30PM. RN A wrote that the medications received were Ativan, Morphine Haldol, total comfort kit. RN A wrote that she had stored the medications in the narcotic lock box. Record

review of policy titled PCU027-Medication Storage in the Facility dated 2025 revealed the following:1.

Medication and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel or members lawfully authorized to administer medications. a. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. Medication storage areas are kept clean, well lit, and free of clutter.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Toscana at Cypress Woods

15015 Cypress Woods Medical Dr Houston, TX 77014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

for 11 months. The ADM stated the DON, ADON and nursing staff are responsible for MC audits. The ADM stated that if there were medications at the bottom of the MC, then there could be possibility that the resident did not receive the medication. Record review of policy titled PCU027-Medication Storage in the Facility dated 2025 revealed the following:1. Medication and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel or members lawfully authorized to administer medications. a. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. Medication storage areas are kept clean, well lit, and free of clutter.

Event ID:

Facility ID:

If continuation sheet