Health inspection·June 5, 2025

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 establish and 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 diseases and infections including hand hygiene procedures to be followed by staff involved in direct resident contact for 2 (Resident #1 and Resident #2) of 6 residents reviewed for infection control. Residents Affected - Some 1.-The facility failed to ensure proper hand hygiene and infection control procedures, when LVN A applied clean dressing without washing/sanitizing her hands or changing her gloves during Resident #1's catheter care on 06/05/2025. 2.-The facility failed to ensure proper hand hygiene and infection control procedures, when RN B initiated catheter care for Resident #2 without washing/sanitizing her hands prior to donning gloves at the start of care. RN B failed to remove her gloves and wash/sanitize her hands throughout Resident #2's catheter care on 06/05/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #1s face sheet dated 06/05/2025 reflected Resident #1 was a [AGE] year-old male admitted on [DATE] with a primary diagnosis of Acute Cystitis without Hematuria (a bacterial infection of the bladder, without blood in the urine), and secondary diagnosis of infection and inflammatory reaction due to indwelling urethral catheter (a hollow tube inserted through the urethra into the urinary bladder to drain urine.) Record review of Resident #1's Entry Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's admission MDS assessment was not due for completion. Record review of Resident # 1's undated care plan revealed the following: Problem: The resident has a suprapubic catheter r/t(related to) benign prostatic hyperplasia without lower urinary tract symptoms. Goal: The resident will show no s/sx (sign and symptoms) of urinary infection through review date. The resident will be/remain free from catheter-related trauma through review date. Interventions: Suprapubic cath (catheter) care q (each) shift and PRN (as needed). Page 1 of 3 455876 455876 06/05/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's face sheet dated 06/03/2025 reflected Resident #2 was a [AGE] year-old male admitted on [DATE] with a primary diagnosis of Flaccid Hemiplegia Affecting Left Dominant Side (a condition where the left side of the body, experiences paralysis with limp, floppy muscles due to neurological damage). Record review of Resident #2's quarterly MDS assessment, dated 04/01/2025, revealed a BIMS (Brief Interview for Mental Status) score of 13 out of 15 which suggests intact cognitive function. Record review of Resident # 2's undated care plan revealed the following: Problem: The resident has a suprapubic catheter and is at risk for infection/trauma Goal: The resident will be free of catheter related trauma through review date. Interventions: Suprapubic cath care q shift and PRN. In an observation on 06/05/2025at 10:13 am with LVN A as she performed suprapubic catheter care on Resident #1. LVN A washed her hands, donned (process of putting on protective gear) a gown, and applied clean gloves. LVN A cleaned the table with sani-wipes, removed gloves, washed hands, and then applied new gloves. LVN A applied Normal Saline to a cup with 4x4 gauze inside, then cleaned around the site from the inside to the outside with one 4 x 4 gauze at a time, and then took a 4x4 gauze and cleaned the foley line from starting from the entrance site and going outwards a few inches. LVN A applied a new, clean dressing without sanitizing her hands or changing her gloves. In an observation on 06/05/2025at 10:29 am with RN B as she performed suprapubic catheter care on Resident #2. RN B put clean gloves on and put 4x4 gauzes into a cup without first sanitizing or washing her hands. RN B then donned a gown and new gloves without first sanitizing or washing her hands. RN B then picked up a trash can with the same gloves and proceed to remove the old dressing. RN B assessed the site which looked red and crusty. RN B removed her gloves and applied new gloves without sanitizing or washing her hands. RN B cleaned the site from the inside to the outside with one 4x4 gauze each time and then the actual catheter line starting with the closest end to the site and going outward. RN B then applied a clean dressing without washing/sanitizing her hands or changing gloves. In an interview on 06/05/2025 at 11:15 am with RN B, she said she forgot to wash/sanitize her hands before starting Resident #2's catheter care and by not doing so infection could happen. RN B said she forgot to change her gloves and wash/sanitize her hands before putting on a clean dressing also, and that could cause an infection. RN B said washing/sanitizing hands was to prevent infection. RN B said that she had been trained on infection control prior to entrance. In an interview on 06/05/2025 at 11:17am with LVN A, she said she forgot to change her gloves and wash/sanitize her hands before putting on a clean dressing during Resident #1's catheter care. LVN A said the reason for changing gloves was to prevent cross contamination. LVN A said the reason for washing/sanitizing hands was to prevent germs. In an interview on 06/05/2025 at 11:15am with RN B, she said she forgot to wash/sanitize her hands before starting Resident #2's catheter care and by not doing so infection could happen. RN B said she forgot to change her gloves and wash/sanitize her hands before putting on a clean dressing also, and that could cause an infection. RN B said washing/sanitizing hands was to prevent infection. LVNA said that she had been trained on infection control prior to entrance. 455876 Page 2 of 3 455876 06/05/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 06/05/2025 at 11:29 with the DON, she said there wasn't a specific procedure for suprapubic catheter care, it was done with routine Activities of Daily Living (ADL) care, and not specific site care. She said that it was her expectation that nursing staff wash/sanitize their hands first prior to care. She said that the nurse should then apply gloves, remove the dirty dressing, take off the dirty gloves, wash/sanitize hands, and apply clean gloves. She said that the nurse should then use 1 4x4 gauze soaked with normal saline, at a time and clean from the inside to the outside of the stoma site. She said that the nurse should use 1 4x4 gauze to wipe at a time and clean the drainage tube starting closest to the stoma and going outwards. She said that the nurse would remove the dirty gloves, wash/sanitize their hands, apply clean gloves, and then apply the clean dressing. She said that by not washing/sanitizing hands and changing gloves could cause an infection control issue. Record review of the facility's policy titled Hand Hygiene dated 10/24/2022 read in part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all location within the facility. Definitions: Hand hygiene is a general term for leaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to , the attached hand hygiene table . Hygiene table, CDC(Center for Disease Control) recommendations for hand hygiene, Prior to direct contact with residents, Before donning sterile gloves for procedures, after contact with a resident's skin, after contact with blood or body fluids, and after removing gloves .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves 455876 Page 3 of 3