Health inspection·June 2, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 5%, based on 2 errors out of 37 opportunities, which involved two of three residents (Resident #203 and Resident #205) and two of three staff (RN A and MA A) observed during medication administration, in that: Residents Affected - Few -RN A failed to administer Amantadine (antiviral that can also be used to treat Parkinson's) to Resident #203 during the medication administration pass. -MA A failed to administer Folic Acid (Vitamin used to treat anemia) to Resident #205 during the medication administration pass because it was unavailable. These failures placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: Resident #203 Record review of Resident #203's admission Record on 6/1/23 at 12:22 p.m., revealed he was a [AGE] year-old male, residing on hall 100 and admitted to the facility on [DATE] with the following diagnoses: epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbances, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially impairment of memory and abstract thinking and often with personality changes), and Gastrostomy status (an opening into the stomach from the abdominal wall, made surgically). Record review on 6/1/23 at 9:06 a.m., Resident #203's Physician Order Summary Report dated 6/1/23 revealed an active order for: Amantadine HCI oral Solution 50 MG/ML Give 10 ml via G-Tube two times a day related .Communication Method .Prescriber Written . Order Status . Active .Order Date .05/29/2023 .Start Date .05/30/2023. Record review of Resident #203's Medication Administration Record (MAR) for 6/1/2023-6/30/2023 revealed the Amantadine HCI oral solution 50mg/5ML Give 10 ML via G-Tube two times a day was scheduled for 08:00 a.m. and 4:00 p.m. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 676201 Printed: 05/15/2026 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 676201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 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)