Health inspection·April 10, 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 two residents (Resident #2) Residents Affected - Few reviewed for infection control and prevention, in that: The facility failed to ensure the Wound Care Nurse properly changed gloves during wound care for Resident # 2 on 04/09/2025. This failure placed residents with wounds at risk for infection, prolonged healing, worsening of existing pressure injury, new pressure injury formation and hospitalization. Findings included: Record review of Resident #2's admission Record, dated 04/09/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included chronic pain, cellulitis of buttock, muscle wasting and atrophy, cognitive communication deficit, and sepsis. Record review of Resident # 2's MDS assessment dated [DATE] revealed: Section C500-Brief Interview of mental status was coded as 8, which indicated, moderate cognitive impairment. Section GG0115 -Functional ability was coded as 2, indicating impaired on bilateral lower extremities. Resident # 2 was totally dependent on staff for activities of daily living. Section H0300-Bladder and bowel status was coded as 3, always incontinent. Section M0100- Skin Condition was coded an A, Resident # 2 has a pressure ulcer. Section M0150, coded as 1, at risk for developing pressure ulcer. Section M1200-revealed to have pressure reducing devices for bed, pressure ulcer care provided. Section M0300 coded as 1 for stage 3 pressure ulcer. Record review of Resident # 2's care plan dated 02/17/2025 revealed: Pressure injury/injuries-Resident # 2 has a stage 2 pressure injury to his sacrum -left lower buttock. Focus: Has pressure injury/injuries and is at risk for further skin breakdown, infection, worsening of existing pressure injury, new pressure injury formation. Goal: Pressure injuries will show signs and symptoms of improvement through the target date 05/12/2025. Intervention: Perform treatment per order. Record review of wound treatment order for Resident # 2 dated 3/11/2025 revealed: Sacrum. Cleans with wound cleanser/ normal saline (ns), then pat dry. Apply honey then cover with bordered gauze dressing daily and PRN. Every day shift for wound care and as needed. Page 1 of 2 675085 675085 04/10/2025 Paradigm at Woodwind Lakes 7215 Windfern Rd Houston, TX 77040

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation of Resident # 2's wound care on 04/09/2025 at 11:34 am, Wound Care Nurse (WCN) was assisted by Certified Nurse Assistant (CNA) B. The WCN checked the orders, knocked on the door, went in, introduced himself and explained he would be performing wound care. The WCN cleansed the sterile field on the over bed table. Sanitized, donned gloves, and gathered required supplies. The WCN doffed gloves, sanitized hands, donned gloves and carried supplies into the room and placed on the sterile field. The WCN doffed gloves, performed handwashing, and put gown on. WCN forgot an item, took off gown and placed in trash, and went out to gather additional supplies. Upon returning with supplies the door was closed for privacy. WCN performed handwashing, puts on treatment gown, and donned gloves. CNA B assisted in repositioning resident. WCN cleaned wound bed with ordered cleanser. He used the first gauze in cleansing the wound. He then folded the gauze and reused it with three different strokes on different areas. WCN then used the same gloves he used in cleansing the wound, to apply honey to the wound per wound care order using a wooden tongue blade. WCN used the same dirty gloves to apply a dressing to the wound. WCN performed peri care changed brief and repositioned the resident. Bed was placed in lowest position, and the call light was placed within reach. During an interview with WCN at 11:48 am, the investigator told the WCN he did not change his gloves before applying honey treatment. He said, Ok but I did not touch the honey treatment directly. I used a tongue blade. When asked of the consequences of not changing gloves from wound bed cleansing to applying treatment, the WCN said there was a possibility of infection, the wound can be septic, possible need for antibiotic and possible hospitalization. During an interview with the Director of Nursing (DON), she said if a Resident requires pain medication prior to wound care treatment and it was not administered to the Resident, they will have pain during treatment. She stated Resident #2 was administered pain medication at 11:08 am prior to his wound care. When asked the consequences of a WCN not changing gloves during the different stages of wound treatment, she said cross contamination might occur and a delay in the wound healing. When asked about wound care training for nurses, DON said training was done by Nursing administration and corporate that comes in and assist with trainings. Record review of facility's dressing change policy, undated, reflected Confirm treatment order. prepare equipment and supplies needed outside the room. identify Resident/explain the procedure to the Resident. Asses for pain/ pre-medicate as necessary. Provides for privacy. Perform hand hygiene. Applies personal protective equipment as necessary. Position Resident comfortably. Apply gloves. Removes old dressing. Inspect wound, note any odors. Discard of dressing and gloves appropriately. Perform hand hygiene. Apply gloves. Cleanses wound as ordered, pat dry with gauze. Discard disposable supplies and gloves appropriately. Perform hand hygiene. Apply gloves. Apply medications/ topicals as ordered. Covered with ordered dressing/dressings. Removes gloves and required PPE. Disposes of soiled equipment properly. Assists resident to a comfortable position. Perform hand hygiene. Document completion on the EMAR/ETAR. 675085 Page 2 of 2