Health inspection·July 8, 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, interviews, and record reviews, 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 disease and infection for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for infection control, in that: - CNA J failed to wear PPE for EBP, when she provided incontinence care to Resident #1.- CNA H failed to sanitize her hands and change her gloves before putting a new brief on Resident #2 and the resident was on contact precautions for MRSA in the urine.- CNA M failed to wear PPE for EBP, when she provided incontinence care to Resident #3.- CNA G failed to wear PPE for EBP, when she provided incontinence care to Resident #4. These deficient practices could place residents at-risk for infection, sepsis, and hospitalization due to cross contamination. Findings included: Record review of Resident #1's undated face sheet revealed he was a [AGE] year-old male originally admitted on [DATE], with the most recent admission date of 6/19/25. He had diagnoses which included: cerebral infarction (stroke), pressure ulcer of right hip, protein-calorie malnutrition, pressure ulcer of right heel, end stage renal disease (kidneys are not functioning), on dialysis (machine filters blood instead of kidneys), contractures (shortening/hardening of muscles/tendons) of right knee and left knee, and hemiplegia and hemiparesis (paralysis and numbness) of left side (weakness/paralysis). Record review of Resident #1's Quarterly MDS Assessment, dated 3/28/2025, revealed a BIMS score of 8 out of 15 which indicated moderately impaired cognition. The MDS indicated the resident had impairment on one side of his upper and lower extremities and used a wheelchair. The resident was dependent (the helper does all of the effort, or the assistance of 2 or more helpers is required) with all ADLs. The resident was always incontinent of bowel and bladder. The MDS indicated Resident #1 had 1 unstageable (wound has dead tissue and wound bed cannot be seen) pressure ulcer. It also revealed the resident was on dialysis. Record review of Resident #1's Significant Change MDS Assessment, dated 6/24/2025, revealed the resident had impairment of both sides of his lower extremities and one side of his upper extremities. The MDS also revealed the resident had 2 unstageable pressure ulcers and was on hemodialysis. Record review of Resident #1's care plan dated 12/23/24, had a Focus: Resident #1 had an unstageable pressure injury to the R hip d/t end stage renal disease. The goal was to have no complications from the wound and show improvement during the next 90 days. The interventions included assisting with turning/repositioning, dietary consult, monitor and report to MD and s/s of infection, treatment/wound care per MD orders, padding between pressure points, and pressure relieving mattress. Focus: Resident #1 has an unstageable pressure injury to his R fifth toe d/t ESRD. The goal was to have no complications from wound and show improvement in the next 90 days. The interventions were the same. Focus: Resident #1 has an unstageable pressure injury to the R lateral foot d/t ESRD. The goal was to have no complications from wound and show improvement in the next 90 days. The interventions were the same. Focus: Resident #1 requires dialysis 3 x Residents Affected - Some Page 1 of 6 676412 676412 07/08/2025 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some week and PRN d/t ESRD. The goal was to have no complications or infections through the review date. The interventions included monitoring the access site for s/s of infection and reporting any complications to the MD. Focus: Resident #1 requires EBP to reduce risk of MDRO's. The goal was to remain socially active through the review date. The interventions included donning PPE before entering the resident's room and doffing PPE before exiting and maintaining EBP and using gowns/gloves during high contact care activities. Record review of Resident #1's Physician Orders revealed the following orders from MD S:- Dialysis Q M-W-F [dialysis center] every shift r/t ESRD. Monitor dialysis shunt to L forearm for bruit/thrill and s/s of infection Qshift. Ordered on 6/19/25 at 3:42pm.- Stage 3 (Tissue loss with fat exposed) Pressure Ulcer to R Lateral Foot: Irrigate or cleanse wound bed with NS, Nexodyn Solution or wound cleanser, pat dry and apply or pack (if applicable): Apply Betadine and LOTA, every Tue/Thu/Sat. Ordered on 7/8/25 at 10:46am.Unstageable Pressure Ulcer to R Fifth Toe: Irrigate or cleanse wound bed with NS, Nexodyn Solution or wound cleanser, pat dry and apply or pack (if applicable): Apply Betadine and LOTA, every Tue/Thu/Sat. Ordered on 7/8/25 at 10:48am.- Stage 4 (Tissue loss with exposed bone, tendon, or muscle) Pressure Ulcer to R Hip: Irrigate or cleanse wound bed with NS, Nexodyn Solution or wound cleanser, pat dry and apply or pack (if applicable): Pack wound with Calcium Alginate, apply 4x4 gauze, cover with gauze bordered island dressing, every Tue/Thu/Sat. Ordered on 7/8/25 at 12:39pm. Record review of Resident #1's Hospital Emergency Department notes from 6/10/25 by MD O revealed the resident had a decubitus ulcer on his R hip and he had a fistula in his arm for dialysis on Monday, Wednesday, and Fridays. Record review of Resident #1's Wound Care note from 6/26/25 by MD B revealed he was being treated for his stage 4 pressure ulcer of the R hip, stage 3 pressure ulcer of the R lateral foot, and an unstageable wound to the R fifth toe. Record review of Resident #1's Physician Progress note from 7/3/25 by MD S, revealed he was admitted with a nonhealing wound to the R foot and new drainage to his R posterior hip. The note revealed he had multiple wounds, including his R hip, R lateral foot, and R fifth toe. The note also revealed he had a LUE fistula for dialysis. In an observation on 7/8/25 at 10:22am, Resident #1 was lying in bed on an air mattress. The resident was on EBP due to his multiple wounds and being on dialysis. CNA J provided incontinence care for the resident and did not wear a gown while providing care. In an interview on 7/8/25 at 10:33am, CNA J said EBP was for any resident that had wounds or foleys (tube into bladder to drain urine). She said she was supposed to wear a gown and gloves for close contact, like incontinence care, to protect herself and the resident from infection. She said she just forgot to put the PPE on. Record review of Resident #2's undated face sheet revealed she was an [AGE] year-old female originally admitted on [DATE], with the most recent admission being 5/5/25. She had diagnoses of osteomyelitis (bone infection) of L ankle and foot, ESBL (type of bacteria) resistance, Type 2 diabetes mellitus (body does not produce insulin or resists it), Stage 4 pressure ulcer of L heel, Unstageable pressure ulcer of L ankle, Unstageable pressure ulcer of sacrum (buttock), and yeast infection. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 out of 15, which indicated moderately impaired cognition. The resident was substantial/max assistance (helper does more than half the effort) with all ADLs. The resident had an indwelling catheter (tube into bladder to drain urine) and was always incontinent of stool. The MDS revealed the resident had 1 Stage 3 pressure ulcer, 1 Stage 4 pressure ulcer, and 1 venous and/or arterial (wound in lower extremities caused by decreased circulation) ulcer, and was receiving wound care. Record review of Resident #2's Care Plan dated 1/7/25, revealed a Focus: Resident had catheter present d/t neurogenic bladder (nerves controlling the bladder are damaged). The goal was to remain free of any catheter related complications through the next review. Interventions included monitor/record/report to MD 676412 Page 2 of 6 676412 07/08/2025 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and s/sx of UTI, check tubing for kinks throughout each shift, and position catheter bag and tubing below level of bladder. Focus: Resident required Contact Isolation d/t Candida Auris and MRSA in urine. The goal was to remain socially active through the isolation period. Interventions included hand washing to prevent spread of infection, post isolation precautions on the door to the room, provide protective equipment at entrance to room, and inform staff and visitors of resident isolation requirements. Focus: Resident had impairment of skin, pressure unstageable necrosis (dead tissue) to L lateral foot. The goal was to heal without complications. The interventions included performing treatments per order and notify MD and RP of any skin concerns/progress. Focus: Resident had impairment of skin, pressure unstageable to L dorsal (top) foot. The goal was to heal without complications. The interventions included performing treatments per order and notify MD and RP of any skin concerns/progress. Resident had a stage 4 pressure injury to L heel. The goal was to have no complications from the wound. The interventions included assist with turning/repositioning during rounds and as needed, heel protectors to be worn when in bed, and keep family/RP and MD informed of resident's progress. Resident had an unstageable pressure injury to sacrum. The goal was to have no complications from the wound. The interventions included assist with turning/repositioning during rounds and as needed, heel protectors to be worn when in bed, and keep family/RP and MD informed of resident's progress. Record review of Resident #2's Physician Orders revealed the following orders from MD S:- Foley catheter 16 Fr (size), 10cc bulb to bedside drainage bag-Diagnosis: Bladder neck obstruction, PRN change foley catheter for s/s of infection, obstruction or if compromised AND every shift foley catheter care, AND every shift record foley catheter output AND PRN change foley drainage bag. Ordered on 5/6/25 at 3:50pm.- Type of wound: Stage 4 Pressure, Location of wound: Sacrum, Irrigate or cleanse wound bed with Normal saline, Nexodyn (type of wound cleanser) solution or wound cleanser, pat dry and apply or pack (if applicable): Collagen powder with Hydrogel gel (wound care products), Cover with: gauze bordered island dressing, every other day AND every 24hrs PRN. Ordered on 5/21/25 at 11:02am.- Cleanse open wound to: Stage 4 wound to L heel, L dorsal foot and L lateral (outside) foot clean with Vashe (wound cleanser), pat dry with gauze, pat periwound (skin and tissue immediately surrounding a wound) area with skin prep (makes skin sticky). Apply negative pressure dressing over the wound bed and secure with adhesive transparent dressing, every Tue, Thu, Sat for open wound AND document number of sponges used for each dressing change AND monitor negative pressure machine for proper functioning and settings AND negative pressure may be disconnected up to 2 hours per 24 hours. If longer than 2hrs notify MD. AND PRN if machine alarms, check dressing seal AND as needed if unable to maintain seal, remove dressing and apply a wet to dry dressing and notify MD AND set negative pressure machine setting at 80MmHg and check for proper functioning every shift. Ordered on 5/21/25 at 11:10am.- Clean L foot with Vashe, apply Wnd Vac at 120-125mmHg continuous, change 3 x week, every day shift every Tue, Thu, Sat for Open wnd. Ordered on 7/4/25 at 11:52am.- Contact Isolation, every day and every shift for C. Auris, MRSA in urine. Place contact precautions sign up on door and on isolation caddie. Staff must wear gown and gloves. Ordered on 7/6/25 at 11:45pm Record review of Resident #2's Nursing Progress Notes from 7/7/25 by LVN W, revealed the resident remained on contact isolation, was on IV abx for a UTI/MRSA, had a foley catheter in place, and had a wound vac in place to the L foot. In an observation on 7/8/25 at 10:36am, Resident #2 was lying in bed on an air mattress, with a pillow to her L side. She had a contact isolation sign on her door and a foley catheter hanging to the side of her bed. In an observation and interview on 7/8/25 at 3:01pm, CNA H provided foley care to Resident #2 and between throwing away the dirty brief and putting on a clean brief, she did not change her gloves. CNA H proceeded to touch the resident's linen, call light, and bed side table 676412 Page 3 of 6 676412 07/08/2025 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some while the resident was on contact precautions for MRSA in the urine. CNA H said she forgot to change her gloves. Record review of Resident #3's undated face sheet, revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of pressure induced deep tissue damage of L heel, Parkinson's disease (progressive neurodegenerative disorder that primarily affects movement), personal history of TIA (mini stroke) and CVA (stroke), hemiplegia and hemiparesis following CVA affecting R side, dementia (decline in mental ability severe enough to interfere with daily life), and anemia (low iron). Record review of Resident #3's admission MDS assessment dated [DATE] revealed a BIMS of 5, which indicated severely impaired cognition. The MDS revealed the resident had impairment on one side of his upper and lower extremities and he was dependent when it came to toileting. The resident was always incontinent of bowel and bladder. The MDS revealed the resident had 1 unstageable pressure injury presenting as a deep tissue injury and he was receiving wound care. Record review of Resident #3's Care Plan dated 6/18/25, revealed a Focus: Resident had a (DTI) pressure injury to L heel d/t skin integrity. The goal was to have no complication from the wound. The interventions included assisting with turning/repositioning during rounds and as needed, monitoring and reporting to MD/RP and s/s of infection and performing treatment/wound care per orders. Focus: Resident required EBP to reduce risk of MDROs. At risk for infection AEB chronic wound. The goal was to remain socially active through the review date. Interventions included donning PPE before entering resident's room and doffing PPE before exiting, maintaining EBP, and staff to use gown and gloves during high contact care activities. Focus: Resident had impairment of skin to R buttock d/t skin integrity. The goal was for it to heal without complications. Interventions included monitoring and reporting to MD/RP and s/s of infection and performing treatment/wound care per orders. Record review of Resident #3's Physician Orders revealed the following orders from MD C:- Type of wound: DTI, Location of wound: L heel, Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Skin prep, every other day AND every 24hrs PRN. Ordered on 6/20/25 at 12:06pm.- Enhanced Barrier Precautions, every shift for wounds with high contact care activities, every shift, every day. Ordered on 6/23/25 at 3:25pm.- Type of wound: Post Surgical Wound, Location of wound: R hip, Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Gauze bordered island dressing, every other day AND every 24hrs PRN. Ordered on 7/1/25 at 4:15pm.- Type of wound: Trauma Injury, Location of wound: R buttock, Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Collagen powder mix with hydrogel gel, cover with gauze bordered island dressing every other day AND every 24hrs PRN. Ordered on 7/6/25 at 12:21pm. Record review of Resident #3's Wound Care Note from 7/3/25 by MD B revealed he was treating the resident's non-pressure wound of the R buttock and an unstageable DTI of the L heel. In an observation and interview on 7/8/25 at 1:48pm, CNA M provided incontinence care to Resident #3 without a gown on while the resident was on EBP. CNA M said EBP was for residents with wounds, feeding tubes, and foleys and that she was supposed to wear a gown to prevent infection to the resident and to her. She said she forgot to put a gown on because she did not see an isolation cart outside of the resident's room. Record review of Resident #4's undated face sheet revealed he was [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (body does not make insulin or resists it), pressure induced deep tissue damage of R heel, Stage 3 pressure ulcer of sacral region, dementia (decline in mental ability severe enough to interfere with daily life), and metabolic encephalopathy (brain dysfunction arises from systemic metabolic disturbances and not structural). Record review of Resident #4's admission MDS assessment dated [DATE], revealed a BIMS score of 4 out of 15, which indicated severely impaired cognition. 676412 Page 4 of 6 676412 07/08/2025 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident was dependent with toileting hygiene. The MDS revealed the resident had an indwelling catheter and was incontinent of bowel. The MDS also revealed the resident had 1 Stage 3 pressure ulcer and 1 unstageable pressure injury presenting as deep tissue injury, and he was receiving wound care. Record review of Resident #4's Care Plan dated 6/2/25, revealed a Focus: Resident had a catheter present and was at risk for UTI and complications d/t catheter use r/t Stage 3 pressure ulcer. The goal was for the foley catheter to remain patent and for the resident to not develop increased UTIs through the review date. The interventions included positioning the bag and tubing below, monitor for s/sx of discomfort, encourage fluid intake, and monitor/record/report to MD s/sx of UTI. Focus: Resident has a Stage 4 pressure injury to his L buttock d/t diabetes. The goal was to not have any complications from the wound. The interventions included assisting with turning/repositioning during rounds and as needed, monitor and report to MD/RP and s/s of infection, and perform treatment per order. Focus: Resident had an unstageable pressure injury to his L heel d/t diabetes. The goal was to have no complications from the wound. Interventions included assisting with turning/repositioning during rounds and PRN, monitor and report to MD/RP and s/s of infection, and perform treatment per order. Focus: Resident had a Stage 4 pressure injury to his R buttock d/t skin integrity. The goal was to have no wound complications. Interventions included, assisting with turning/repositioning during rounds and PRN, monitor and report to MD/RP and s/s of infection, and perform treatment per order. Focus: Resident required EBP to reduce risk of MDROs. At risk for infection AEB chronic wounds, and current use of indwelling device. The goal was to remain socially active through the review date. Interventions included donning PPE before entering the resident's room and doffing PPE before exiting, maintaining EBP, and staff to use gown and gloves during high contact care activities. Record review of Resident #4's Physician Orders revealed the following orders from MD I:- Enhanced Barrier Precautions (EBP), every shift, every day with high contact activities. Ordered on 5/29/25 at 8:49am.- Foley catheter: 16Fr 10cc bulb to bedside drainage bag Dx: personal history of malignant neoplasm of prostate w/ new pelvic mass PRN change foley catheter for s/s of infection, obstruction or if compromised AND every shift foley catheter care, AND every shift record foley catheter output AND PRN change foley drainage bag. Ordered on 5/30/25 at 9:00am.- Type of wound: Unstageable pressure, Location of wound: L heel, Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Betadine LOTA AND every 24hrs PRN. Ordered on 6/9/25 at 9:09am.- EMAR Negative pressure machine monitoring, every shift for open wound. Every shift monitor negative pressure machine for proper functioning and settings AND every shift negative pressure may be disconnected up to 2hrs per 24hrs. If longer than 2hrs notify MD AND PRN if machine alarms, check dressing seal (may reinforce dressing as needed) AND every 24hrs as needed if unable to maintain seal, remove dressing and apply a wet to dry dressing and notify MD. Ordered on 7/7/25 at 8:46am.- Cleanse open wound to: L and R buttock with NS or WC, pat dry with gauze, pat periwound area with skin prep. Apply negative pressure dressing over the wound bed and secure with adhesive transparent dressing, every Tue, Thu, Sat for open wound AND document number of sponges used for each dressing change AND monitor negative pressure machine for proper functioning and settings AND negative pressure may be disconnected up to 2 hours per 24 hours. If longer than 2hrs notify MD. AND every 12hrs PRN if machine alarms, check dressing seal (may reinforce dressing as needed) AND every 12hrs as needed if unable to maintain seal, remove dressing and apply a wet to dry dressing and notify MD AND set negative pressure machine setting at 125MmHg continuous and check for proper functioning every shift. Ordered on 7/7/25 at 8:48am. Record review of Resident #4's Progress Note from 7/1/25 by NP P revealed he had a foley with clear, yellow urine output. It also revealed he had a Stage 3 pressure ulcer 676412 Page 5 of 6 676412 07/08/2025 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to his L buttocks. Record review of Resident #4's Wound Care Note from 7/3/25 by MD B, revealed he was being treated for his Stage 4 pressure wound of the R buttock, Stage 4 pressure wound of the L buttock, and his unstageable wound to his L heel. In an observation and interview on 7/8/25 at 2:45pm, Resident #4 was laying on his back in bed with a gown on. CNA G was performing foley care to Resident #4. CNA G did not wear a gown during foley care, while the resident was on EBP. CNA G said a gown and gloves were required to be worn during resident care when a resident was on EBP, to prevent infection to the resident and herself. She said she forgot to put the gown on before providing foley care. In an interview on 7/8/25 at 12:55pm, the DON said staff were required to wear a gown and gloves for direct care with any resident with g-tubes (tube into stomach for nutrition), foleys, or wounds. She said direct care included peri care, showers, wound care, and incontinent care. The DON said EBP was to prevent staff and residents from cross contamination. Record review of the facility's policy and procedure on Perineal Care (Revised 1/2024) read in part: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Perineal care refers to the care of the external genitalia and the anal area. Perform hand hygiene and put on gloves. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. Thoroughly dry. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. Record review of the facility's policy and procedure on Enhanced Barrier Precautions (Revised 4/2024) read in part: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities include: Dressing, Bathing, Transferring, Providing hygiene, Changing briefs or assisting with toileting, Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, or Wound care. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 676412 Page 6 of 6