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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675085
Printed: 05/15/2026
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
675085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Woodwind Lakes
7215 Windfern Rd
Houston, TX 77040
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
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675085
If continuation sheet
Page 2 of 2
