Woodway Nursing & Rehab

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

admissions. Interview on 11/05/25 at 1:14PM with Housekeeper E said she was assigned to Resident #1's room. She said the last time Resident #1's room was cleaned was on 11/04/25. She said it was herself and another housekeeper that was cleaning and that she did not know if the other housekeeper had cleaned resident room thoroughly. She said it was important for the residents' rooms to remain clean prior to admission and discharge to prevent the spread of bacteria. Interview on 11/06/25 at 8:50AM with the Administrator, she said the NF had started an in-service on Infection Control with the staff on 11/05/25 due to Resident #1's room not being cleaned. The Administrator said the residents' rooms should be cleaned every day. The Administrator said if a resident is discharged from the facility the resident's room should be deep cleaned, and everything should be removed from the room and placed in the storage room. The Administrator said before a resident is admitted to a room, the room had to be cleaned to prevent infections. The Administrator said there was a gap in communication with the housekeeping department regarding the cleaning of Resident #1's room. The Administrator was asked to provide the facility policy on Physical Environment. The Administrator was asked to provide the facility policy on Physical Environment

on 11/06/25 at 4:30PM. Record review of the NF policy on Resident Rights revised June 10, 2025, reflected

in part: .The resident has a right to a safe, clean, comfortable environment and homelike environment including but not limited to receiving treatment and supports for daily living safely.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodway Nursing & Rehab

2808 Stoneybrook Drive Houston, TX 77063

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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents. She said due to the NF not having a Clinical Marketer, she was asked by the COO if she could assist with referrals. She said she was familiar with the referral process from prior experience. Attempted

interview on 11/06/25 at 11:27AM via phone with the NP, no answer, left voicemail with call back number.

Interview on 11/06/25 at 11:55AM with LVN F, she said she worked the morning shift from 6AM-6PM full time. LVN F said she had been working at the NF for almost a year. LVN F said if a resident was admitted to

the NF without the NF receiving a report on the resident, she would immediately call the hospital to get a full report on the resident. LVN F said she would inform the doctor, Administrator and the ADON since the facility did not have a DON at present what had taken place. LVN F said whenever a resident missed a scheduled dose of their antibiotic therapy, it placed the resident at risk of the infection developing resistance to the antibiotic causing the resident to be given a stronger antibiotic to treat the infection. LVN F said it also placed other residents at risk of encountering that same bacteria. Interview on 11/06/25 at 2:03PM with Resident #1's Doctor, he said he was notified on 11/06/25 by the ADON that Resident #1 had missed several doses of his IV antibiotic therapy. Dr. said because resident was already receiving frequent scheduled doses at the hospital, he was not concerned about the missed doses and would extend the length of days for resident to receive the IV antibiotic therapy and continue to have the staff monitor resident vital signs and order labs as needed. The doctor said more than likely the infection had resolved itself, but antibiotic therapy was extended a little longer for precautionary measure due to resident having

the following tubes (tracheostomy, gastrostomy, and Foley catheter). The Dr. said it was the NP that the facility would first call upon admission and then he would follow-up. The Doctor said the NP had sent him a message on 11/06/25 in the morning informing him that Resident #1 had returned to the facility and what antibiotics he was receiving for diagnosis of pneumonia and what bacteria was being treated. The Doctor said Resident #1 had a history of sepsis and going in and out of the hospital. The Doctor said Resident #1 would continue to get infections due to having tubes inside of his body which the body looks at as a foreign object and would begin to attack. The Doctor said it was an ongoing process. The Doctor said the infection would go away until another infection occurred and had to be treated. The Doctor said eventually no antibiotic would help and Resident #1 would eventually pass away. The Administrator was asked for the NF policy on Pharmacy Services on 11/06/25 at 4:30PMRecord review of the NF policy on Resident Rights revised June 06, 2025 reflected in part: .Resident has the right to receive the services and /or items included in the plan of care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodway Nursing & Rehab

2808 Stoneybrook Drive Houston, TX 77063

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)

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 control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 4 residents (Resident # 2,) reviewed for infection control in that: CNA D failed to don (to put on) disposable gown when providing direct care for Resident #2 who was on Enhanced Barrier Precautions on 11/05/25.

This failure could place residents at risk for cross-contamination and unwanted infections. Findings include:

Record review of Resident #2's face sheet dated 11/06/25 revealed a [AGE] year-old-female admitted to the NF originally on 06/29/24 and again on 07/02/25. Resident #2's diagnoses consisted of the following: heart disease, type 2 diabetes mellitus (high blood sugar levels), pneumonia (infection in the lungs), dysphagia (difficulty swallowing), gastrostomy (surgical procedure to insert a feeding tube in to the stomach to allow liquid nutrition and medicine), end stage renal disease (irreversible kidney disease where the kidneys are no longer able to function on their own), renal dialysis (medical procedure to remove waste from the blood), and cerebral infarction (blockage in the brain that cuts off blood flow to the brain). Record review of Resident #2's quarterly MDS dated [DATE REDACTED] revealed a BIMS score of 7 indicating that Resident #2's cognition was severely impaired. Record review of Resident #2's Comprehensive Care Plan dated 06/06/25 revealed that resident was being care planned for feeding tube being in place with intervention to wear abdominal binder. Record review of Resident #2's Physician Order Summary Report for the month November 2025 reflected the following orders: -Dated 05/31/25 Enhanced Barrier Precaution every day and night shift.-Dated 08/11/25 Every shift Nepro continuous pump assist via peg at 55ml/hr x 22 hours to provide a total 1946 ml/day, may give Glucerna 1.5 pending Nepro available. Observation on 11/05/25 at 10:18AM on Resident #2's door entrance was an EBP signage on the door with the door closed. The signage instructed staff to don PPE gown and gloves. There was a 3-drawer plastic storage bin by resident door entrance with gloves and blue disposable gowns inside of the drawers. Coming out of Resident # 2's room was CNA D with clear plastic bags in her hand. Inside of bag the surveyor did not see a blue disposable gown in the bag. Interview 11/05/25 at 10:18AM with CNA D, she said she had just finished providing incontinent care for Resident #2. CNA D said she did not put on a disposable gown while providing direct care for Resident #2. CNA D said she was supposed to do this for infection control and got

in a hurry to get resident ready to go to dialysis. CNA D said she placed resident and herself at risk for infections. Observation on 11/05/25 at 10:20AM of Resident #2 resting in bed awake with feeding pump on

the left of bed with feeding disconnected from resident. CNA D said she was about to transfer resident from bed to chair. Resident had a gastrostomy tube with dressing around gastrostomy site dated 11/05/25.

Interview on 11/06/25 at 2:50PM the ADON said she was the facility's Infection Control Preventionist. The ADON said all nursing staff should be practicing Enhanced Barrier Precaution when providing direct care for a resident that had the following: gastrotomy tubes, Foley catheter tube, tracheostomy, IV lines, etc.

ADON said the staff should be wearing gloves and gowns. The ADON said when the staff was not donning correct PPE there was risk for cross contamination. Record of the NF policy on Infection Prevention and Control Prevention revised April 04, 2025 reflected in part: .This facility has established and maintains 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 as per accepted national standards and guidelines .

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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