Health inspection·April 3, 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 Unknown A and Unknown B failed to use proper PPE for Enhanced Barrier resident (Resident #1). The facility failed to ensure Unknown A and Unknown B wore appropriate PPE when entering Resident #1s' room on 03/13/2025 who was on Enhanced Barrier precautions while they performed direct care. These failures could place residents at risk for spread of infection. Findings included: Record review Resident #1's face sheet, dated 02/26/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Anoxic Brain Damage (Brain damage caused by complete lack of oxygen supply to the brain, leading to cell death and potential neurological impairments), Respiratory Failure (A condition where the lungs are unable to adequately perform their primary function of gas exchange, resulting in either insufficient oxygen in the blood (hypoxemia) or excessive carbon dioxide levels (hypercapnia), Type 2 Diabetes Mellitus Diabetic Hyperglycemia (A Condition where blood sugar (glucose) levels are persistently elevated), Alzheimer's Disease (A progressive brain disorder that primarily causes memory loss and cognitive decline, eventually affecting a person's ability to perform everyday tasks), Chronic Kidney Disease Stage 3 (Moderate kidney damage, meaning your kidneys are less able to filter waste and fluid from your blood), Tracheostomy Status (A person's current situation regarding having a tracheostomy), Persistent Vegetative State (A neurological condition where a person is awake but lacks awareness of a self or surrounding, with no purposeful behavior or interaction), Unspecified Dementia (A dementia diagnosis where the specific type and severity are not determined, and there are no co-occurring behavioral, psychotic, mood or anxiety symptoms), Aphasia (A language disorder that affects a person's ability to communicate). Record review of Resident #1's care plan, dated 11/06/24, reflected a focus area that Resident #1 had a tracheostomy related to acute respiratory failure Interventions: .Use Enhanced Barrier Precautions. Record review of Resident 1's quarterly MDS assessment, dated 02/12/25, reflected a BIMS score of 0, which indicated cognition was severely impaired. Section O- Respiratory Treatment- E1. Page 1 of 4 675901 675901 04/03/2025 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0880 Tracheostomy Care. Level of Harm - Minimal harm or potential for actual harm Record review of screenshots of Resident #1's video monitoring dated 03/13/25 with a time stamps of 7:01 AM revealed Unknown A and Unknown B providing direct care to Resident #1. Unknown A did not have on a mask or gown. Unknown B did not have on a gown. Residents Affected - Few During an observation on 04/03/25 at 11:28am of Resident #1's room door revealed an Enhanced Barrier Precautions signage that stated, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linen, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. During an interview on 4/03/25 at 11:32 AM, the DON stated when staff are working with a resident with contact isolation they are to DONN and DOFF PPE. She stated there was an Enhanced Barrier signage outside of the door and the PPE carrier was hanging on the doors of residents that are on Enhanced Barriers. Surveyor showed DON pictures taken from video monitoring of Resident #1's room in which staff did not have on gowns or mask while providing direct care to Resident #1 who was on Enhanced Barriers Precautions. She stated she was unsure of who the exact staff were in the pictures. She stated the staff should always have on PPE whenever providing direct care to a resident that has Enhanced barrier signage outside of the door. She stated the risk of not wearing proper PPE while providing direct care to resident who are on Enhanced Barrier Precautions could be a risk for the staff and the resident for spreading organisms. She stated she was not aware that the staff were providing care without PPE. During an interview on 04/03/25 at 11:43 AM, the ADON/IP who stated a staff member should never provide direct contrat without PPE to a resident that was on contact isolation. She stated she was not aware that staff were providing care to the resident without the proper PPE. She stated the risk of not having full PPE on while providing are to a resident that has Enhanced Barriers was transferring infection to others and cross contamination. Record review of the facility's policy on Infection Control, revised date of 03/2024, reflected, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Procedures: 1. Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include: a. Proper selection and use of PPE such as gowns, gloves, facemasks, respirators, and eye protection 675901 Page 2 of 4 675901 04/03/2025 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0880 i. Level of Harm - Minimal harm or potential for actual harm Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). Residents Affected - Few .3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities from indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: b. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: i. Dressing ii. Bathing/showering iii. Transferring iv. Providing hygiene v. Changing linens vi. Changing briefs or assisting with toileting vii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary 675901 Page 3 of 4 675901 04/03/2025 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0880 catheter, feeding tube, tracheostomy/ventilator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675901 Page 4 of 4