Tuscany Village

F-F689: Free of Accident Hazards/Supervision/Devices

Immediate Action Taken:

1. All nursing personnel Including RN, LVN, CNA, CMA have been retrained on how to:

o Access and view individual patient records.

o Perform assigned safety tasks based on each resident's individualized care plan.

o Properly document the completion of these tasks.

Record review and interview conducted on [DATE REDACTED] of in-service document dated [DATE REDACTED] did reveal that facility staff had been in serviced on

o Access and view individual patient records.

o Perform assigned safety tasks based on each resident's individualized care plan.

o Properly document the completion of these tasks.

2. This training was provided by the Director of Nursing and her designee through in-service sessions, completed on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 676201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676201 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tuscany Village 2750 Miller Ranch Rd Pearland, TX 77584

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 0689 This was confirmed by conducting interviews with facility staff on [DATE REDACTED].

Level of Harm - Immediate 3. The resident rounding policy was reviewed and updated by the Medical Director, Director of Nursing, and jeopardy to resident health or Administrator on [DATE REDACTED]. It now includes the creation of an individualized safety plan for each resident based safety on their specific needs. Interventions may include, but are not limited to:

Residents Affected - Few o Frequent safety checks.

o Use of low beds and fall mats.

o Scheduled toileting.

o Participation in activities.

o Contacting families to provide resources for sitter services.

o Use of non-slip socks.

o Discharge to home with a one-on-one care arrangement.

This information was confirmed by conducting interviews of RN, LVN, CMA, and CNA on [DATE REDACTED]. The staff told me that their administration had in serviced them on improved safety plan for residents. Also record

review was conducted of in-service training sheets dated [DATE REDACTED].

4. These interventions will be determined by the nurse conducting the assessment. All staff have been trained on these updates before providing care, with training completed as of [DATE REDACTED].

Medical Director Notification:

The Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator on [DATE REDACTED].

________________________________________

Facility's Plan to Ensure Compliance:

1. A Performance Improvement Plan (PIP) has been implemented, requiring each charge nurse to conduct a daily chart review. This review ensures that nurse aides are completing individualized safety checks for residents in a timely manner. The chart review will cover 25% of the assigned caseload.

Record review on [DATE REDACTED] of the PIP reflected that it was implemented and signed by facility staff on [DATE REDACTED] at 12:30pm.

2. The findings from these chart reviews will be documented on a PIP assignment sheet and submitted to the Director of Nursing.

3. All staff received training on this new protocol on [DATE REDACTED], led by the Director of Nursing and the Administrator. This training was completed on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 676201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676201 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tuscany Village 2750 Miller Ranch Rd Pearland, TX 77584

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 0689 Record review on [DATE REDACTED] reflected that this training did occur on [DATE REDACTED].

Level of Harm - Immediate 4. The Director of Nursing, or her equivalent, will review the logs weekly to ensure compliance with safety jeopardy to resident health or audits and the fulfillment of each resident's safety measures. safety

Record review on [DATE REDACTED] reflected that this training/in-service did occur on [DATE REDACTED]. Residents Affected - Few 5. The findings of these weekly reviews will be reported during the monthly QAPI (Quality Assurance and Performance Improvement) meetings. If necessary, the QAPI team will initiate changes and retrain staff accordingly.

Record review was conducted on [DATE REDACTED] and it reflected that a QAPI team was in serviced on [DATE REDACTED].

________________________________________

1:45pm-Interview with LVN-B on [DATE REDACTED] LVN-B was able to tell me that she had been in serviced on fall risks, documentation of falls, fall prevention, frequent rounding, and assessments of residents.

1:53pm-Interview with CNA-B on [DATE REDACTED] CNA_B said that she had been recently in serviced that staff need to frequent rounds more, meaning every two hours or as needed depending on the resident. She was able to tell me that if a resident is a fall risk, then the resident's bed should be in lowest position and falls mats may be placed next to the resident's bed.

2:00pm-Interview with CNA-C on [DATE REDACTED] CNA-C told me that he had been in serviced on rounding more frequently at least every two hours or [NAME] depending on the resident. He also was able to tell me that if a resident is a fall risk their bed should be in lowest position and fall mats may also be placed next to their bed.

2:05pm-Interview with CNA-D she told me that her in-service was about rounding frequently and more depending on the residents. And that if a resident has a fall, they should not move the resident until they have been assessed.

2:22pm-Interview with LVN- C on [DATE REDACTED] LVN-C said that she had been in serviced on frequent rounding, charting fall prevention, and assessment.

2:35pm-Interview with CNA-E on [DATE REDACTED] CNA-E told me that her in service was about frequent rounding and at least every two hours or [NAME] depending on the condition of the resident. She was also able to tell me that a resident should not be moved until and assessment has been performed.

2:40pm-Interview with CMA-A on [DATE REDACTED] CMA-A said that when she is passing out meds, she makes sure to watch to see if any residents or in distress. She said that her in-service was about frequent rounding. She also said that if a resident is on the floor, then that resident should not be moved before being assessed.

2:45pm Observations were conducted on [DATE REDACTED] throughout the facility. Staff were attending to resident's needs; call lights were being answered and services were being provide to residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 676201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676201 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tuscany Village 2750 Miller Ranch Rd Pearland, TX 77584

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 0689 2:56pm-Interview with LVN-D on [DATE REDACTED] LVN-D said she was in serviced on frequent rounding, fall risk prevent, assessments, and charting of residents falls. Level of Harm - Immediate jeopardy to resident health or 3:35pm-Interview with CNA-F on [DATE REDACTED] CNA-F said she was able to tell me that her in service was on safety rounding at least every two hours or [NAME] depending on the resident's condition and a resident should not be moved until they have been assessed. Residents Affected - Few 3:50pm-Phone interview with LVN- A on [DATE REDACTED] LVN-A told me that she had been in serviced via telephone.

She was able to tell me about rounding and her responsibility as a nurse regarding charting.

An Immediate Jeopardy (IJ) was identified on [DATE REDACTED]. The IJ template was provided to the facility on [DATE REDACTED] at 5:00pm. While the IJ was removed on [DATE REDACTED] at 4:36 pm, the facility remained out of compliance scoped at isolated with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 676201