Tuscany Village Nursing Center

In the surveyor’s words

From the most serious findings on record at Tuscany Village Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Apr 10, 2023

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to ensure Resident #1 received CPR for one (#10) of two sampled residents for CPR. Resident #1 was admitted to the facility on [DATE] and had diagnoses which included end stage renal disease, hypertension, diabetes mellitus II, iron deficiency and anemia. Resident #1 admitted late in the day and the facility documented TBD as the Resident's code status. No assessments were completed at the time of admission. Resident #1's documentation from the hospital dated [DATE] documented they were a full code status. On [DATE] the fire department arrived to facility at 2:01 p.m. […]

• Immediate jeopardy, isolatedF689Jul 8, 2021

  On 06/30/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to supervise a resident to prevent elopement, failure to perform 30-minute visual checks, and failure to ensure consistent and uninterrupted one-on-one supervision after the residents' return to the facility. On 06/26/21 at approximately 4:00 p.m., resident #1 was observed attempting to exit the front door and again around 4:45 p.m. The resident was redirected both times back to the nurse's station. It was reported the resident was last seen at approximately 5:00 p.m. attempting to exit the facility from the 300 hall exit door, triggering the door alarm. […]

• Actual harm, patternF550Feb 7, 2022

  Based on observations, interviews, and record reviews, the facility failed to ensure residents were treated with dignity for one (#8) of one sampled resident reviewed for dignity. This resulted in the resident feeling miserable, un-digitized and he wanted to die. The administrator identified 126 residents resided in the facility. Findings: Resident (Res) #8 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Res's care plan, dated 07/20/21, documented to respect the Res's privacy. The Res's quarterly assessment, dated 01/12/22, documented the Res's cognition was intact. Res #8's ADL report, dated 01/15/22, documented the Res was totally dependent on staff for bed mobility and toilet use. […]

• Actual harm, patternF600Feb 7, 2022

  Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for one (#8) of four sampled resident reviewed for dignity. This resulted in the resident feeling miserable, un-dignified and he wanted to die. The administrator identified 126 residents resided in the facility. Findings: A facility policy titled, Neglect, revised 06/23/17, read in part, .Each resident has the right to be free from neglect .The facility must prohibit and prevent .neglect .Neglect: Failure of the facility .to provide .services to a resident that are necessary to avoid .mental anguish, or emotional distress . […]

• Actual harm, patternF686Feb 7, 2022

  Based on record review and interviews, the facility failed to ensure pressure ulcers did not develop and weekly skin assessments were conducted for two (#1 and #2) of three sampled residents reviewed for pressure ulcers. This resulted in resident #2 developing an unstageable pressure ulcer. The DON identified 18 residents had wounds. Findings: 1. Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 12/22/21 at 11:12 p.m., read in part, .Resident admitted to facility .skin CDI [clean, dry, intact] without redness or open areas noted . An admission resident assessment, dated 12/26/21, documented the resident required extensive assistance for transfers and bed mobility and had no un-healed pressure ulcers. […]