Health inspection·May 2, 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 control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 of 3 residents (Residents #1) reviewed for infection control. Residents Affected - Few The facility failed to ensure LVN-A and CNA-B wore gowns while providing catheter care to Resident #1 who was on EBP. This failure could affect residents who required assistance with catheter care and could place residents at risk for cross contamination and infections. The finding included: Record review of Resident #1's admission Record, dated 04/29/2025 revealed a [AGE] year-old man initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included: Cerebral Palsy (a congenital disorder of movement and muscle tone) and Obstructive and Reflux Uropathy (condition where urine cannot drain through urinary tract and urine can back up into the kidneys). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating normal cognitive function. He was assessed as having an in-dwelling catheter. Record review of Resident #1's Care Plan, initiated 10/01/2016, revealed the resident required a Supra-pubic catheter (a small flexible tube inserted directly into the bladder through a small incision in the lower abdomen to drain urine), related to diagnosis of urinary retention. Record review of Resident #1's Order Summary dated 04/29/2025 revealed an order for enhanced barrier precautions related to suprapubic catheter. Observation on 05/01/2025 at 10:10 a.m. revealed LVN-A and CNA-B were performing catheter care to Resident #1, wearing gloves but no gowns. There was an EBP sign posted outside Resident #1's door. During an interview with LVN-A on 05/01/2025 at 10:20 a.m., LVN-A stated he knew he should have put on a gown in addition to the gloves to perform catheter care for Resident #1, because any residents with indwelling catheters should be on enhanced barrier precautions. LVN-A stated he knew what enhanced barrier precautions were and had received training in infection control, but just forgot to put on the gown. He stated that not wearing a gown while providing direct care to a resident with a catheter could result in spread of infection. Page 1 of 2 676224 676224 05/02/2025 The Heights on Huebner 10127 Huebner Rd San Antonio, TX 78240

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/01/2025 at 10:38 a.m. with CNA-B revealed he knew what the EBP sign outside Resident#1's door meant and that he should have worn a gown when he was cleaning Resident #1. He stated he had been trained about EBP, but just forgot. He stated that by not wearing a gown while working directly with Resident #1, it could result in the spread of germs. During an interview with the DNS on 05/01/2025 at 12:11 p.m., the DNS stated that the staff should have worn both gown and gloves when providing direct care, such as catheter care to Resident #1, and that not following EBP precautions would increase the risk of spreading infection. Record Review of the facility's policy titled Infection Prevention and Control revised April 2024, revealed EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing . and Residents/patients with the following clinical indication should be under EBP: Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. 676224 Page 2 of 2