Health inspection·January 5, 2024

F 0880 Provide and implement an infection prevention and control program. 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 maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #5) reviewed for infection control, in that: Residents Affected - Few While providing incontinent care for Resident #5 CNA A did not wash or sanitize her hands between change of gloves, before touching the resident's briefs and after cleaning the resident's buttocks' area. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #5's face sheet, dated 01/05/2024, revealed a [AGE] year old female resident with an admission date of 09/19/2023, with diagnoses which included: Encephalopathy (disorder or disease of the brain), History of urinary tract infection (an infection in any part of the urinary system), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Alcohol abuse (unhealthy drinking behavior). Record review of Resident #5's Quarterly MDS, dated [DATE] revealed Resident #5 had a BIMS score of 5, indicating severe cognitive impairment. Resident #5 was coded as always incontinent of bowel and bladder. Record review of Resident #5's Optional State assessment MDS revealed Resident #5 needed extensive assistance with her activities of daily living. Review of Resident #5's care plan, dated 09/19/2023, revealed a problem of FUNCTIONING DEFICIT- I have physical functioning deficit related to: Dx: Encephalopathy/, with an intervention of Toileting assistance of one. Observation on 01/05/2024 at 9:19 a.m. revealed while providing incontinent care for Resident #5, CNA A cleaned Resident #5's buttocks, changed her gloves, then placed a clean brief on the resident. CNA A did not wash or sanitize her hands, between change of gloves, before touching the clean briefs and fastening the briefs to the resident. During an interview with CNA A on 01/05/2024 at 9:25 a.m., CNA A verbally confirmed she did not (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 2 Event ID: 455549 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 455549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jourdanton Nursing and Rehabilitation 1504 Highway 97e Jourdanton, TX 78026 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)