Health inspection·November 2, 2023

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 for 2 of 3 residents reviewed (Residents #3 and #4) for infection control., in that: Residents Affected - Some 1. CNA B failed to wash her hands after performing incontinent care for Resident #3. 2. LVN A failed to don PPE when entering Resident #4's room. These failures could place residents at risk of contracting a communicable disease. Findings included: Resident #3 1. Record review of Resident #3's face sheet revealed reflected a [AGE] year-old male who was admitted into the facility on [DATE] and had diagnoses which included with stage 4 chronic kidney disease and benign prostatic hyperplasia. Record review of Resident #3's MD orders, dated 11/02/2023, revealed the resident was ordered to be on contact isolation precautions for C. Diff (Clostridioides difficile) that causes inflammation of the colon and can be transmitted from person to person by spores. The order was started on 09/15/2023 with no end date. Observations of Resident #3's room on 09/16/2023 at 4:00 PM revealed CNA B entered the room, to provide incontinent care, there was no soap available to use for handwashing in the room. CNA B doffed her used PPE and left Resident #3's room to wash her hands in a handwashing station across the hall . In an interview with CNA B on 09/16/2023 at 4:15 PM, she stated she was told yesterday Resident #3 had C. Diff. She stated she had to come out of the room to wash her hands because there was no soap in the room. She stated her leaving the room to wash her hands was an infection control issue . She said she was not sure who was in charge for keeping the soap in stock, but she believed it was an activities staff. In an interview with the ADON on 09/16/2023 at 4:20 PM, she stated if CNA B went from touching Resident #3 to the handwashing station across the hall without performing hand hygiene in between, that (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: 675714 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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)