Health inspection·September 12, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complication) for 1 (Resident #1) of 15 residents reviewed for physician notification. The facility failed to consult with the physician when Resident #1 developed a rash on her arms, legs, and back. These failures could place residents at risk of not having their physician informed and residents not receiving adequate medical interventions, not having their care needs met, not being seen by physicians, and not receiving adequate and timely interventions, which could cause a decline in physical and psychosocial health and even death. Findings included: Record review of Resident #1's face sheet reviewed on 09/11/24 revealed an eighty-five-year-old woman who was admitted on [DATE]. Her admitting diagnoses were dementia, anxiety disorder, malnutrition, and hypertension. Record review of Resident #1'sQuarterly MDS (comprehensive nurse assessment) Section C- Cognitive Patterns revealed that she had a score of 8 (moderately impaired) out of 15. Record review of Resident #1's care plan initiated 04/06/24 reflected that Resident #1 resided in the secure unit, related to a diagnoses of dementia, risk for elopement, and disoriented to place. She had impaired cognitive function or impaired thought processes related to dementia. Interventions initiated 04/18/24 were to keep her routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Record review or Resident #1's progress notes created by LVN C on 09/04/24 at 2:05 pm reflected patient picks at her skin until it turns red at times. Record review of Resident #1's Weekly Skin assessment dated on 08/23/24 completed by WCN revealed that no areas of concern were noted. This was the last skin assessment notated in Resident #1's documentation portal. Record review of Resident #1's Weekly Skin Assessment completed by LVN A on 08/16/24 reflected that Page 1 of 8 676239 676239 09/12/2024 Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1 had a rash on her entire body. In Section B labeled Notification, Part A asked if there were any new areas that had not been communicated to the Physician/NP or family. This question was answered with No. Record review of Resident #1's Weekly Skin assessment dated on 08/09/24 reflected that Resident #1 had a rash located on her arms, legs, chest, and back. In Section B labeled Notification, Part A asked if there were any new areas that had not been communicated to the physician/NP or family. This question was answered with No. Record review of Resident #1's MAR (medication administration record) for the Month of August 2024 revealed that she received a 10 MG of Zyrtec, for allergies, oral tablet one time a day for itching. Record review of Resident #1's MAR for September 2024 reflected that she received a topical Eucerin Itch Relief External Lotion 0.1 % to be applied all over the body one time a day for itching. Record review of Resident #1's prescription orders revealed that she started Eucerin Itch Relief External Lotion 0.1 % on 06/20/24, Zyrtec Allergy Oral Tablet 10 MG on 06/05/24, Prednisone Oral Table 20 MG on 09/11/24, Hydrocortisone External Cream 1% on 9/12/24, and Ketoconazole external shampoo 2% on 09/12/24. Record review of Resident #1's shower sheet sign-off documented that she received a shower on 9/09/24, 09/07/24, 09/05/24, and 09/03/24. Record review of Resident #1's wound care note documented that on 09/10/24, Resident #1 was seen by the facility WCN, WCD, and Physician A. It was determined that Resident #1 had a skin condition called puritis (an itchy feeling or sensation on the skin that makes you want to scratch) and she was recommended oral steroids. In an interview on 09/11/24 at 2:33 pm with LVN E, she stated that on the MC Unit, there were a few residents who were itching and scratching. She stated that when Resident #1 was admitted 4 months ago, she would itch and scratch her arms and stomach. Her physician thought it was an allergy and she was placed on an allergy medication and a cream. At that time, Resident #1 had small red marks with bumps on her legs and arms. During this interview, Resident #1 walked up. In an observation and interview with Resident #1 on 09/11/24 at 2:40 pm, she walked up to the State Investigator and LVN E, she was scratching her arm vigorously. On her right arm, there were several small red bumps that covered her entire arm. Resident #1 stated that she was itching a lot and believed that the small red bumps may have been caused by mosquitos because she was outside. LVN E looked at the bumps and stated that her skin looked like it had gotten worst. In an interview on 09/11/24 at 2:46 pm with LVN D, she stated that she seldom worked in the MC unit, but as of lately she did because LVN A was on vacation. She explained that Resident #1 was currently prescribed Eucerin cream, and she received a dose that morning because of a rash. LVN D stated that she had not noticed any small red bumps on her skin and if she did notice a rash, she would document it, tell the physician, and follow the treatment. She explained that having a rash was not Resident #1's baseline and she would document it every week until there was not a rash anymore. In an interview on 09/11/24 at 3:03 pm, the DON stated that she began working at the facility in 676239 Page 2 of 8 676239 09/12/2024 Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some July 2024. The nurse who normally worked on the MC Unit was LVN A, but she was on vacation from 09/03/24- 09/16/24. She explained that nurses were to do skin assessments weekly and the CNA's should be reporting changes to the nurses on resident shower days. She stated it was up to the ADON or the DON to ensure that skin assessments were completed in a timely manner. She stated that she had not heard that any residents in the MC unit were picking or scratching their skin and she had no knowledge that Resident #1 had a rash or was experiencing any itching. She stated that medication orders could be approved by any nurse, which meant that she did not have to view them first, and she did not always meet with the Physician after viewing a resident. The DON stated that if there was a rash on Resident #1, it should have been reported to herself, the nurse, or the WCD who visited the facility weekly. The DON was asked to review Resident #1's records with the State Investigator. It was noted that Resident #1 began the Eucerin cream before she started to work at the facility and per her diagnoses, it was not a part of her baseline. In an observation and interview on 09/11/24 at 3:23 pm, the DON and the State Investigator walked with Resident #1 into her room so that the DON could take a look at her skin. The DON raised Resident #1's shirt to view her back. There were several red marks on her back. Her skin was red, and it appeared to have a lot of small, red dots. The DON then began to pull up the sleeves on her arms, then she pulled her pant legs up to her thighs. There were several small red bumps all over her upper and lower extremities, with the largest amount on her right arm. Resident #1 stated that was the first time her skin had ever looked like that and she itched really bad. In an interview on 09/12/24 at 11:46 am, LVN B stated that when he saw Resident #1 that day, she didn't mention anything to him about her skin. He stated that her PA visited her on Tuesday 09/10/24 and she was given a new order of prednisone (steroid used to treat inflammation or severe allergic reactions). He stated that no nurses or CNA's had mentioned to him about Resident #1 having a rash on her body, but she had been using a Eucerin cream. LVN B explained that if he noticed a change in a resident's condition, the protocol would be to notify the physician, the DON, and the family. He stated that if a resident had a preexisting skin condition that went away, but returned, it should be documented as a new change in condition and the protocol should be followed. He stated on Tuesday 09/10/24, the WCD, the WCN, and Physician A came to check on Resident #1 because there was a report of her breaking out. In an interview on 09/12/24 at 12:15 pm with Resident #1's PA, he stated that when he saw her on 09/10/24, her skin had a maculopapular rash (a skin condition that appears as a combination of flat, discolored areas, and small raised bumps) all over her body and she was very itchy. When he spoke with the WCD, they decided that the rash did not look like bed bugs or mites, but some type of contact dermatitis. He stated that he prescribed her prednisone to help treat the rash. The PA explained that he had reviewed her previous notes and discovered that she had something similar in June 2024 and it was treated with an antihistamine. He stated that he was informed by the facility's WCN on 09/10/24, who had also informed the WCD about Resident #1's rash. When a change of condition is present in a resident, nurses are supposed to contact a member of their physician team and they will come to the facility as soon as they can or prescribe something to address the problem. In an interview on 09/12/24 at 12:39 pm with Physician A, he explained that he was one of the doctors of a medical group who worked with Resident #1. He stated that she currently had a generalized rash on her body, was being treated with prednisone, and once she got better, she would be referred to a dermatologist for an expert opinion. He stated that he never got a notification that any residents in the MC unit had a skin rash or a bite. If he had known that someone had a rash, he would have come in as soon as he could to see what needed to be done. He stated that staff never let him know 676239 Page 3 of 8 676239 09/12/2024 Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014

F 0580 anything new was going on with Resident #1, so he did not make any alterations to her care. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/12/24 at 1:05 pm, the WCN stated that while he was doing rounds with the WCD on Tuesday 09/10/24 between 11-12am, he noticed Resident #1 walking up and down the hallway scratching. He asked the WCD to view the wound and it was determined that it was not scabies, but a rash. Physician A was also in the building, so the WCN consulted with him as well, and she was prescribed something topical and a steroid pack. He stated that when there was a change in a resident's skin condition, the nurses would notify him, he created a wound note, change in condition assessment, and informed the WCD. If it was not a wound, he would tell the nurse to consult with the doctor and carry out the treatment. The WCN stated that prior to him seeing Resident #1's wound that Tuesday, he had not been told from any of the nurses or CNA's that she had a rash on her body. He stated that after the DON was informed on 09/11/24 of Resident #1's condition, the DON and himself went into the MC unit, and preformed a skin assessment on every resident. Residents Affected - Some In an interview on 09/12/24 at 2:31 pm, the DON stated that the harm in delayed notification to the physician for a resident could be a worsening condition which could result in the need for a resident to be transferred to the hospital. Record review of the facility's policy titled Notifying the Physician of Change in Status revised March 11, 2013 reflected that: 1. The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate attention. 2. The nurse will notify the physician immediately with a significant change in status. The nurse will document signs and symptoms of significant change time/date of call to physician, and interventions that were implemented in the resident's clinical record. 3. If the resident remains in the facility and a significant change has occurred, update the care plan accordingly. 676239 Page 4 of 8 676239 09/12/2024 Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 (Resident #1) of 15 residents reviewed for comprehensive assessments in that. Residents Affected - Few The facility did not complete 2 weeks of Weekly Skin Assessments for Resident #1, which resulted in the development of an unexplained rash. These failures could place residents at risk of not having all medical needs assessed and met in a timely fashion. Findings Included: Record review of Resident #1's face sheet reviewed on 09/11/24 revealed an eighty-five-year-old woman who was admitted on [DATE]. Her admitting diagnoses were dementia, anxiety disorder, malnutrition, and hypertension. Record review of Resident #1'sQuarterly MDS (comprehensive nurse assessment) Section C- Cognitive Patterns revealed that she had a score of 8 (moderately impaired) out of 15. Record review of Resident #1's care plan initiated 04/06/24 reflected that Resident #1 resided in the secure unit, related to a diagnoses of dementia, risk for elopement, and disoriented to place. She had impaired cognitive function or impaired thought processes related to dementia. Interventions initiated 04/18/24 were to keep her routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Record review or Resident #1's progress notes created by LVN C on 09/04/24 at 2:05 pm reflected patient picks at her skin until it turns red at times. Record review of Resident #1's Weekly Skin assessment dated on 08/23/24 completed by WCN revealed that no areas of concern were noted. This was the last skin assessment notated in Resident #1's documentation portal. Record review of Resident #1's Weekly Skin Assessment completed by LVN A on 08/16/24 reflected that Resident #1 had a rash on her entire body. In Section B labeled Notification, Part A asked if there were any new areas that had not been communicated to the Physician/NP or family. This question was answered with No. Record review of Resident #1's Weekly Skin assessment dated on 08/09/24 reflected that Resident #1 had a rash located on her arms, legs, chest, and back. In Section B labeled Notification, Part A asked if there were any new areas that had not been communicated to the physician/NP or family. This question was answered with No. Record review of Resident #1's MAR (medication administration record) for the Month of August 2024 revealed that she received a 10 MG of Zyrtec, for allergies, oral tablet one time a day for itching. 676239 Page 5 of 8 676239 09/12/2024 Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's MAR for September 2024 reflected that she received a topical Eucerin Itch Relief External Lotion 0.1 % to be applied all over the body one time a day for itching. Record review of Resident #1's prescription orders revealed that she started Eucerin Itch Relief External Lotion 0.1 % on 06/20/24, Zyrtec Allergy Oral Tablet 10 MG on 06/05/24, Prednisone Oral Table 20 MG on 09/11/24, Hydrocortisone External Cream 1% on 9/12/24, and Ketoconazole external shampoo 2% on 09/12/24. Record review of Resident #1's shower sheet sign-off documented that she received a shower on 9/09/24, 09/07/24, 09/05/24, and 09/03/24. Record review of the Weekly Skin Assessment Schedule reflect that Resident #1 was scheduled to receive her weekly skin assessment every Friday. Record review of the facility's schedule for Friday, 09/06/24 reflected that LVN B worked the MC Unit from 6am-2pm. Record review of Resident #1's wound care note documented that on 09/10/24, Resident #1 was seen by the facility WCN, WCD, and Physician A. It was determined that Resident #1 had a skin condition called puritis (an itchy feeling or sensation on the skin that makes you want to scratch) and she was recommended oral steroids. In an interview on 09/11/24 at 2:33 pm with LVN E, she stated that she does skin assessments weekly, if there was a change in condition or new admission, for residents in the MC unit. She explained that she was responsible for skin assessments on the front of the hall, and they were to be documented in their resident portal. In that unit, there were a few residents who were itching and scratching. She stated that when Resident #1 was admitted 4 months ago, she would itch and scratch her arms and stomach and she thought that was something that Resident #1 would do. Her physician diagnosed it as an allergy in June 2024 and she was placed on an allergy medication and a cream. At that time, Resident #1 had small red marks with bumps on her legs and arms, but she had not noticed anything on her as of recent. During this interview, Resident #1 walked up to the investigator. In an observation and interview with Resident #1 on 09/11/24 at 2:40 pm, she walked up to the State Investigator and LVN E while scratching her arm vigorously. On her right arm, there were several small red bumps that covered her entire arm. Resident #1 stated that she was itching a lot and believed that the small red bumps may have been caused by mosquitos because she was outside. LVN E looked at the bumps and stated that her skin looked like it had worsened since the last time she saw it. In an interview on 09/11/24 at 2:46 pm with LVN D, she stated that she seldomly worked in the MC unit, but as of lately she did because LVN A was on vacation. LVN D stated she could not recall doing a skin assessment for Resident #1 since she had been filling in on that unit. Since LVN A was gone, any nurse was able to give skin assessments, but it depended on who was assigned which rooms. She explained that Resident #1 was currently taking Eucerin cream, and she received a dose that morning because of a rash. LVN D stated that she had not noticed any small red bumps on her skin and if she did notice a rash, she would document it, tell the physician, and follow the treatment. She explained that having a rash was not Resident #1's baseline and she would have documented it in the resident portal every week until there was not a rash anymore. In an interview on 09/11/24 at 3:03 pm, DON stated that she began working at the facility in July 676239 Page 6 of 8 676239 09/12/2024 Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2024. The nurse who normally worked on the MC Unit was LVN A and she was on vacation from 09/02/2409/16/24. She explained that nurses were to do skin assessments weekly and each resident was assigned a day to receive their assessment. She stated CNA's should be reporting changes to the nurses on resident shower days. DON stated that the ADON and herself were responsible for ensuring that skin assessments were completed in a timely manner and since she had been working at the facility, she had not done any in-services on skin assessments, change in condition, or recognizing changes in the skin. She stated that she had not heard that any residents in the MC unit were picking or scratching their skin and she had no knowledge that Resident #1 had a rash or was experiencing any itching. She stated that medication orders could be approved by any nurse, which meant that she did not have to view them first or speak with the Physician after he visited with a resident to know if there were any changes in their care. DON stated that if there was a rash on Resident #1, it should have been reported to herself, the nurse, or the WCD who visited the facility weekly. If the rash had dissolved an reappeared a few week [NAME], it should have still been documented as a change in condition until that rash had dissolved again. DON was asked to review Resident #1's records with the State Investigator. She saw that Resident #1 began the Eucerin cream before she started to work at the facility and per her diagnoses, it was not part of her baseline. In an observation and interview on 09/11/24 at 3:23 pm, the DON and the investigator walked with Resident #1 into her room so that the DON could take a look at her skin. The DON raised Resident #1's shirt to view her back. On her back, there were several red marks on her back. Her skin was red, and it appeared to have a lot of small, red dots. The DON then began to pull up the sleeves on her arms, then she pulled her pants legs up to her thighs. There were several small red bumps all over her upper and lower extremities, with the largest amount on her right arm. Resident #1 stated that was the first time her skin and had ever looked like that and she itched really bad. In an interview on 09/12/24 at 11:46 am, LVN B stated that when he saw Resident #1 that day, she didn't mention anything to him about her skin. He stated that her PA visited her on Tuesday 09/10/24 and she was given a new order of prednisone. He stated that no nurses or CNA's had mentioned to him that Resident #1 had a rash on her body, but she had been using a Eucerin cream. He stated that aids were to report any changes in skin conditions during shower and Resident #1 was scheduled to receive showers on Tuesday, Thursday, and Saturday. LVN B explained that if he noticed a change in a resident's condition, the protocol would be to notify the physician, the DON, and the family. Afterwards, he would do a SBAR form and an assessment that pertained to whatever changed the resident was experiencing. For instance, he stated that if someone had a fall, he would perform a fall assessment and for changes in the skin, he would have completed a skin assessment. LVN B stated that if a resident had a preexisting skin condition that went away, but returned, it should be documented as a new change in condition and the protocol should be followed. All nurses were responsible for documenting changes in a resident, but different nurses were responsible for performing weekly skin assessments. He stated that he worked Friday 09/06/24 but he said that he did not do the skin assessment because he may not have had enough time. He explained that if would have known that Resident #1 had a rash, he would have told the WCN, DON, and completed her assessments. The first time he was aware of Resident #1's rash was when the WCD, WCN, and Physician A saw her on 09/10/24. In an interview on 09/12/24 at 12:15 pm with Resident #1's PA, he stated that when he saw her on 09/10/24, her skin had a maculopapular rash (a skin condition that appears as a combination of flat, discolored areas, and small raised bumps) all over her body and she was very itchy. When he spoke with the WCD, they decided that the rash did not look like bed bugs or mites, but some type of contact dermatitis. He stated that he prescribed her prednisone to help treat the rash. The 676239 Page 7 of 8 676239 09/12/2024 Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PA explained that he had reviewed her previous notes and discovered that she had something similar in June 2024 and it was treated with an antihistamine. He stated that he was informed by the facility's WCN on 09/10/24, who had also informed the WCD about Resident #1's rash. When a change of condition is present in a resident, nurses are supposed to contact a member of their physician team and they will come to the facility as soon as they can or prescribe something to address the problem. They would also do a full assessment of the resident and create a note in the resident's portal or the Physician relayed the plan of care to the nurse so that they could create a progress note. In an interview on 09/12/24 at 12:39 pm with Physician A, he explained that he was one of the doctors of a medical group who worked with Resident #1. He stated that she currently had a generalized rash on her body and was being treated with prednisone and once she got better, she would be referred to a dermatologist for an expert opinion. He stated that staff never let him know anything new was going on with Resident #1 so he did not make any alterations to her care. In an interview on 09/12/24 at 1:05 pm, the WCN stated that while he was doing rounds with the WCD on Tuesday 09/10/24 between 11-12am, he noticed that Resident #1 was walking up and down the hallway scratching. He asked the WCD to view her skin and it was determined that it was not scabies, but a rash. Physician A was also in the building, so the WCN consulted with him as well, and she was prescribed something topical and a steroid pack. He stated that when there was a change in a resident's skin condition, the nurses would notify him, he created a wound note, change in condition assessment, a skin assessment, and informed the WCD. If it was not a wound, he would tell the nurse to consult with the doctor and carry out the treatment. The WCN stated that he reviewed Resident #1's previous skin assessments, he saw that she had a mention of a rash, but no one informed him of this rash. After the DON was informed on 09/11/24 on Resident #1's condition, the DON and himself went into the MC unit and preformed a skin assessment on every resident to make sure there were preexisting conditions and all assessments were up to date. In an interview on 09/12/24 at 2:31 pm, the DON stated that the harm in a delayed completion of the skin assessment could be a worsening condition which could result in the need for a resident to be transferred to the hospital. She stated that she had no idea that Resident #1 had missed weeks of skin assessments and this delay in documentation resulted in a delay in care. A policy on skin assessments was requested on 09/12/24 at 2:30 pm. This policy was not provided to the State Investigator. 676239 Page 8 of 8