Health inspection·November 20, 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 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 (Resident #1 and #2) out of 2 residents reviewed for infection control, in that Residents Affected - Few The facility failed to ensure CNA B changed glove and performed hand hygiene during incontinent care for Resident #1 and Resident #2. The facility failed to ensure CNA B cleaned Resident #1's anus during incontinent care. These failures could place residents living in the facility at risk of exposure to infections. Findings include: Review of Resident #1's face sheet revealed a [AGE] years old female initially admitted to the facility on [DATE]. Her current admission was on 06/15/2023. Her diagnoses included Lymphedema (Swelling in the body, arm or leg caused by a blockage in the lymph.), cellulitis of limb (a condition characterized by bacterial infection of the skin that causes redness, swelling, and pain in the infected area of the skin.), hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone.), Type 2 diabetes mellitus (characterized by high levels of sugar in the blood), hyperlipidemia (A condition in which there are high levels of fat particles in the blood). Review of Resident #1's MDS dated [DATE], section G revealed Resident #1 required one-person extensive assistance with toilet use and personal hygiene. Review of Resident #1's Care plan dated 06/19/2023 revealed resident had an ADL self-care performance deficit related to activity intolerance, impaired balance/ impaired coordination and she was a 1 to 2 person dependent for ADLs and 1 person assistance with personal hygiene. The goal was for Resident #1 to maintain a sense of dignity by being clean, dry, odor free, and well-groomed. Intervention was to assist resident with personal hygiene, toileting, bed mobility, transfer, dressing, locomotion on and off the unit. On 11/10/2023 at 4:43am during observation of incontinent care. CNA B performed incontinent care on Resident #1. CNA B wiped Resident #1's perineum at the front and at the back. She wiped resident's bottom but failed to separate resident's bottom fold to clean the anus. CNA B reached out to pick the zinc oxide ointment to be applied to resident's perineum area when Surveyor intervened and stopped the CNA B. Surveyor told CNA B that she did not clean the Resident #1 very well all the way to the (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 3 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 11/20/2023 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)