Health inspection·April 10, 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 diseases and infections for 1 (Residents #1) out of 3 residents reviewed for infection control, in that: Residents Affected - Few The facility failed to ensure CNA B contained the dirty wipes after cleaning Resident #1; CNA B threw the used wipes across Resident #1 to the trash can located at the opposite side of the bed whilre providing incontinent care to Resident #1. The facility failed to ensure that CNA C did not put clean gloves in her scrubs pocket during incontinent care for Resident #1. These failures could increase the spread of infection and place residents living in the facility at risk of exposure to infections. Findings include: Record review of face sheet revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His diagnoses include need for assistance with personal care, hypertension, acute respiratory failure, overactive bladder, communication deficits, shortness of breath, muscle wasting, constipation, generalized anxiety disorder, cognitive communication deficit. Record review of MDS (minimum data set) dated 2/28/2024 revealed Resident #1 needed extensive assistance for ADL care and required one-person physical assistant. Record review of the care plan dated 3/10/2024 revealed Resident #1 had impaired functional mobility and required assistance with ADLs, with interventions included to assess the degree of functional impairment and assist resident with ADL's (Activity of Daily Living) based on the current level of mobility. On 04/08/2024 at 3:15pm in an observation, CNA B was providing incontinent care on Resident #1. CNA B was cleaning Resident #1 and she was throwing the wipes across the bed to the other side where the trash can was located, some of the wipes fell on the floor. CNA C was assisting CNA B during the incontinent care. CNA C removed gloves from her scrubs pocket and donned them during the incontinent care. On 04/08/2024 at 3:35pm in an interview with CNA B, she stated she had training on infection (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: 676155 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 676155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503 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)