Health inspection·March 5, 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 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 one of three residents (Resident #1) reviewed for infection control. Residents Affected - Few 1. RT A failed to wash her hands or use hand sanitizer between gloves changes while providing Tracheostomy (Trach) care for Resident #1. 2. RT A failed to ensure she did not double glove in placed of hand hygiene while providing Tracheostomy Care. These failures could place residents at risk for spread of infection. Findings include: Record review Resident #1's face sheet, dated 03/05/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs are unable to exchange oxygen and carbon dioxide properly, resulting in low oxygen levels in the blood), dependence of respirator (ventilator) status, hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high), diabetes (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), Chronic Obstructive Pulmonary Disease (a condition caused by damage to the airways or other parts of the lung), and Tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Record review of Resident #1's care plan, dated 12/31/24, reflected a focus area that Resident #1 had a tracheostomy and was at risk for changes in secretions, infection, and respiratory distress. Record review of Resident 1's quarterly MDS assessment, dated 01/04/25, reflected a BIMS score of 15, which indicated cognition was cognitively intact. Section O- Respiratory Treatment- E1. Tracheostomy Care. During an observation on 03/05/25 at 10:59 AM revealed Trach Care was provided by RT A. RT A entered Resident #1's room and placed Trach supplies on the bedside table. RT A donned mask, gown, and gloves. RT A was observed donning another pair of gloves on top of the initial pair of gloves she already had on (RT A had 2 pair of gloves on). After suctioning Resident #1, RT A was observed removing Page 1 of 4 455714 455714 03/05/2025 Paradigm Northwest 17600 Cali Dr Houston, TX 77090

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the 2nd layer of gloves, and disposed of them. RT A was then observed opening a Trach care kit and putting sterile gloves on top of the initial pair of gloves she already had on. RT A was observed cleaning Resident #1's Trach site and doffing off after Trach care was completed and using hand sanitizer. Hand washing/ Hand sanitizer was not observed in between glove changes Trach Care. Resident #1's O2 Stat was monitored throughout Trach care and RT A engaged with Resident #1 throughout Trach care ensuring the resident was not in distress. During an interview on 03/05/25 at 11:30 AM with RT A, she stated she was not seen sanitizing her hands while in Resident #1's room because she had just sanitized them before leaving the nurses station prior to entering the room. She stated they were supposed to sanitize their hands before and after suctioning the resident. She stated she did not sanitize her hand because she worked with a clean pair of gloves at all times and that was her purpose of having 2 pair of gloves on at all times. During an interview on 3/05/25 at 12:57 PM, the DON stated hands should be washed or use of hand sanitizer used in between glove changes. She stated when trach care was being provided the staff were to sanitize or wash before care and to also let the patient know what was being done. She stated the staff were to use the Trach care kit with the sterile gloves. She stated staff were expected to sanitize or wash hands prior to beginning care, dispose of gloves, perform hand hygiene before putting on sterile gloves, dispose of gloves again and perform hand hygiene again. She stated she was unsure of why RT A used multiple pairs of gloves while providing care and stated it would have been appropriate for RT A to wash her hands or use hand sanitizer in between glove changes. She stated the risk of not performing hand hygiene was infection. Record review of the facility's policy on Tracheostomy Care, revised date of 11/2022, reflected, It is the policy of this facility that Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and stoma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning . Procedures: 1. Review Orders for tracheostomy care (should contain the frequency & type of care) 2. Gather necessary equipment 3. Identify the resident, introduce self, and explain procedure to the resident. 4. Wash hands prior to setting up equipment. 5. 455714 Page 2 of 4 455714 03/05/2025 Paradigm Northwest 17600 Cali Dr Houston, TX 77090

F 0880 Suction resident. Level of Harm - Minimal harm or potential for actual harm 6. Remove drain sponge and disposable inner cannula. Residents Affected - Few 7. Perform hand hygiene with soap and water. 8. Prepare new inner cannula by opening slightly 9. Open normal saline bottle and set aside 10. Open trach care kit 11. Aseptically DON sterile gloves 12. Aseptically place drape on surface and dump contents of kit 13. Place tray on the drape 14. Pour normal saline into tray (may use wound cleanser as indicated) 15. Place sponges / gauze into saline in the tray 16. With a non-dominant hand, pick up new inner cannula and with the dominant hand, replace inner cannula. (Or follow instructions below for non-disposable inner cannula) 17. 455714 Page 3 of 4 455714 03/05/2025 Paradigm Northwest 17600 Cali Dr Houston, TX 77090

F 0880 Cleanse stoma with gauze / applicators Level of Harm - Minimal harm or potential for actual harm 18. Cleanse trach phalange with sponges Residents Affected - Few 19. Replace drain sponge 20. Change tie if soiled 21. NOTE: Monitor 02 saturation throughout procedure 22. Monitor the patient's response to the procedure. If any adverse reaction is noted, discontinue the procedure, and notify physician. 455714 Page 4 of 4