Health inspection·January 28, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ring and call for assistance. She said the staff came into her room at approximately 3:00 a.m. when a blood draw was attempted. She said she had been saturated with urine for over an hour. During an observation and interview on 1/28/2025 at 9:23 a.m. there was no visible staff on the hall. At 9:24 a.m. CNA A was walking down the hall with a cart and picking up breakfast trays. The state surveyor asked if there was another staff member available to assist Resident #1. CNA A said she was not sure. During an interview on 1/28/2025 at 9:27 a.m., CNA A said she was picking up breakfast trays. She said there was another CNA A that helped on the hall but was on another hall. CNA A said she did not go in and check on Resident #1 or check if she needed an incontinent change. She said she had not checked if Resident 1's call bell was in reach. She said CNAs and nurses were responsible and supposed to ensure the call bell was in a resident's reach. She said she started her shift at 6:00 a.m. this morning. She said she opened Resident #1's door, but assumed she was asleep and had not been back to the room. She said because the call light system was out, we were supposed to check on residents every 15-minute checks. She said she went to the door but had not gone into the room . In a further interview and observation on 1/28/2025 at 9:30 a.m., with Resident #1 to CNA A said she was saturated with urine. CNA A said did you use your call light. Resident #1 said she could not find it. CNA A said I can come back after I finish picking up trays. Resident #1 said I would rather not wait. CNA A said I can come back after I finish the trays and give you a shower. Resident #1 said she wanted to be changed now. CNA said she last checked on Resident #1 when she completed her initial rounds at approximately 6:40 a.m., after she came on shift. When CNA A said she did not want to wake up Resident #1 at 6:40 a.m., Resident #1 said she was not sitting up, but she heard CNA A open the door. Resident #1 said no other staff had come in the room and asked if she needed any assistance or made sure her call bell was within her reach. CNA A showed Resident #1's soaked brief that was in a plastic bag after she was changed. CNA A said the blue line down the middle of the brief, indicated it was soiled. She said although [Resident #1] was a heavy wetter, the brief was soaked and had leaked out onto her clothing. She said this could cause the resident discomfort. During an interview on 1/28/2025 at 9:40 a.m., LVN A (sitting at nurse's station) said he had not seen Resident #1. He said he rounded on two other halls. He said LVN B was the nurse for the 600 hall. He said his shift started at 6:00 a.m. During an interview on 1/28/2025 at 9:50 a.m., LVN B said she arrived late for her shift at 6:00 a.m. and LVN A completed shift change. She said she made rounds between 6:30 a.m. and 7:00 a.m. She said she peeked in the door. She said she saw Resident #1 from the room door and verified the resident was in the bed. She said it was the nurses and CNAs responsibility to ensure call bells were within the residents' reach. She said the resident was at risk of not receiving care if they were not able to reach the call bell or notify staff. She said she had been trained to check on residents every 15 minutes and document on a log placed at the nurse's station. During an interview on 1/28/2025 at 10:39 a.m., CNA B said she worked the 6:00 a.m. - 2:00 p.m. shift. She said she had been trained to make room checks every 15 minutes because the call light system was not working. She said she had not been in Resident #1's room since she placed her meal tray on her table at approximately 8:30 a.m. CNA B said she did not check where Resident #1's call bell was within reach. She said she did not check because she was focused on getting breakfast trays delivered. She said CNAs and nurses were responsible for ensuring the call bells were within the residents' reach. She said the resident was at risk for not receiving care or assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 2 of 6 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/28/2028 at 11:38 a.m., RN A said the call bell should be placed within a resident's reach and on their dominant side. She said if a call bell was out of reach, a resident would not be able to call for help or for assistance. She said the CNAs and nurses were responsible for ensuring the call bells were in place. She said staff should check residents every 15 minutes, because the call light system was currently not working. She said staff had been in-serviced on the 15 minutes rounding. She said the DON and the ADON were responsible for ensuring rounds were completed. During an interview on 1/28/2028 at 11:48 a.m., the DON said CNAs and nurses were responsible for ensuring the call bells were in place. She said the also completed Champion Rounds by department head to ensure residents needs were met. She said the Activities Dir. was the department head for the 600 hall. She said if the call bell was not in place, the resident is at risk their needs not met and could reach too far and fall. She said staff should walk and do rounds to ensure the call lights were in place. During an interview on 1/28/2025 at 2:56 p.m., Activity Dir. said she completed the champion that included Resident #1's room. She said she brought Resident #1's mail approximately 9:05 a.m. She said she did not stay in the room long because this state surveyor was in the room with CNA A. She said she picked up a piece of trash. She said she did not check Resident #1's call light. She said she had not been in Resident #1's room before she delivered the mail . Record review of the facility's policy on Perineal Care Female (revised 12/8/2009) read in part the following, e. Always replace call signal and needed items within resident's reach . Record review of the facility policy Resident Rights (not dated) revealed the following in part: The resident has a right to a dignified existence, self-determination . including those specified in this policy. Respect and dignity - The resident has a right to be treated with respect and dignity, including . 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 3 of 6 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain grooming and personal hygiene care for 1 (Resident #1) of five residents reviewed for ADL care. Residents Affected - Some -The facility failed to ensure Resident #1 was provided timely incontinent care. These failures could place residents who required ADL care at risk of not receiving personal care and services. Findings included: Record review of Resident #1's face sheet dated 1/28/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: wrist drop-right wrist (weakness of the muscles that control wrist extension, resulting in the inability to lift the hand or extend the wrist properly), muscle weakness, lack of coordination, muscle wasting, hemiplegia (almost complete paralysis of one side, including loss of movement), and hemiparesis (partial weakness or reduced strength on one side but not complete paralysis) affecting left non-dominant, type 2 diabetes (group of diseases that affect how the body uses blood sugar), and anemia (reduced red blood cells.). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 of 15 which indicated she was cognitively intact. Further review revealed Resident #1 needed partial to moderate assistance with ADLs (Section GG - roll left and right - partial/moderate assistance, toileting hygiene - partial/moderate assistance), (Section H - Urinary and Bowel continence - frequently incontinent) which required at least one staff assistance. Record review of Resident #1's care plan initiated on 4/10/2024 revealed Resident #1 had risk for falls related to hemiplegia/hemiparesis. An intervention was to ensure Resident #1's call light was within reach. Resident #1 had an ADL self-care deficit related to inability to perform activities of daily living independently. Goal was to maintain toilet use and personal hygiene. Intervention required extensive assistance of one staff. During an observation and interview on 1/28/2025 at 9:19 a.m., revealed Resident #1's manual call bell was on her bedside dresser. The dresser was on Resident #1's right side. Resident #1 said she was soaking wet. Resident #1 was wet with urine from front to back, and her bed sheets and temporary bed pad was soaked. She said she was very uncomfortable and frustrated. She said had been saturated with urine for over an hour. During an observation and interview on 1/28/2025 at 9:23 a.m. there was no visible staff on the hall. At 9:24 a.m. a CNA A was walking down the hall with a cart and picking up breakfast trays. Surveyor asked was there another staff available to assist Resident #1. CNA A said she was not sure. During an interview on 1/28/2025 at 9:27 a.m., CNA A said she was picking up breakfast trays. She said there was another CNA that helped on the hall but was on another hall. CNA A said she did not go in and check on Resident #1 or check if she needed an incontinent change. She said she started her shift at 6:00 a.m. this morning. She said she open Resident #1's door approximately at 6:40 a.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 4 of 6 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm but assumed she was asleep and had not been back to the room. She said she had helped in the dining room and assisted with feeding residentsShe said because the call light system was out, we were supposed to check on residents every 15-minute checks. She said she thought CNA B had checked on the resident since she was in the dining room. She said the resident can go without being helped if staff does not round. Residents Affected - Some In a further interview and observation on 1/28/2025 at 9:30 a.m., with Resident #1 to CNA A said she was saturated with urine. CNA A said did you use your call light? Resident #1 said she could not find it. CNA A said I can come back after I finished picking up trays. Resident #1 said I would rather not wait. CNA A said I can come back after I finish the trays and give you a shower. Resident #1 said she wanted to be changed Now. CNA A completed the Resident #1 incontinent change and came out of the room. This surveyor asked to see the saturated brief. CNA A said the brief was heavily saturated. She said the blue line down the middle of the brief indicated the brief was wet. She said Resident #1's clothing had to be changed because it was wet from urine. CNA A said she assisted residents in the dining room with feeding and had not been back to check on Resident #1. During an interview on 1/28/2025 at 9:50 a.m., LVN B said she arrived late for her shift at 6:00 a.m. and LVN A completed shift change. She said she made rounds between 6:30 a.m. and 7:00 a.m. She said she peeked in the door. She said she saw Resident #1 from the room door and verified the resident was in the bed. She said she was not aware Resident #1 was soiled. He said the resident is at risk of not receiving incontinent care which could result in skin breakdown. She said she had been trained to check on residents every 15 minutes and documents on a log placed at the nurse's station . During an interview on 1/28/2025 at 10:39 a.m., CNA B said she worked the 6:00 a.m. - 2:00 p.m. shift. She said she had been trained to make room checks every 15 minutes because the call light system is not working. She said she had not been in Resident #1's room since she placed her meal tray on her table at approximately 8:30 a.m. She said Resident #1 wanted coffee. CNA B said she did not check where Resident #1's call bell was within reach. She said she did not check because she was focused on getting breakfast trays delivered. She said cnas and nurses were responsible for ensuring the residents' incontinent changes were completed timely. She said the resident was at risk for skin breakdown . During an interview on 1/28/2028 at 11:48 a.m., DON said cnas and nurses were responsible for ensuring resident had timely incontinent changes. She said a residents' call bell should be within reach so that the resident can call for assistance. She said saturated briefs could lead to skin breakdown if not changed timely. She said she was not sure why Resident #1 had not been changed timely. She said staff were trained on rounding every 15 minutes because the call system was not working and call bells were being used. Record review of the facility's policy on Perineal Care Female (revised 12/8/2009) read in part the following , . d. Provide for resident's comfort . e. Always replace call signal and needed items within resident's reach . Record review of the facility policy Resident Rights (not dated) revealed the following in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 5 of 6 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 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 0677 The resident has a right to a dignified existence, .including those specified in the this policy. Level of Harm - Minimal harm or potential for actual harm Respect and dignity - The resident has a right to be treated with respect and dignity, including . 3. Residents Affected - Some The right to reside and receive services in the facility with reasonable accommodation of resident needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 6 of 6