Health inspection·December 29, 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 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 1 of 9 residents (Resident #1) observed for infection control practices. The facility failed to ensure LVN A followed standard precautions during wound care on 12/11/2025 for Resident #1's wounds when she failed to perform hand hygiene between glove changes. This failure could place residents at risk for healthcare-associated cross-contamination and infections. Findings included: Review of Resident #1's face sheet dated 12/11/2025 revealed Resident #1 is a [AGE] year-old male who was admitted into the facility on [DATE] with the following diagnoses: Multiple Myeloma (a rare blood cancer of plasma cells in the bone marrow), Paraplegia (paralysis affecting the lower half of the body), Generalized muscle weakness, Anxiety disorder and Stage 4 Pressure Ulcer of sacral region. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating that he was cognitively intact with normal thinking and memory. Resident #1 received the following skin treatments: pressure/ulcer injury care, application of nonsurgical dressings. Review of Resident #1's Comprehensive Care Plan dated 5/3/2025 revealed a focus area for Enhanced Barrier Precautions. Interventions included PPE: Gown and Gloves during high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, wound care). Observation on 12/11/2025 at 10:58 AM revealed LVN A sanitized her hands prior to entering the resident's room. She put on a gown and gloves. She used wound cleanser to clean the sacral wound. She applied calcium alginate collagen to the wound and covered it with the bordered gauze dressing. The nurse changed her gloves. She did not sanitize or wash her hands prior to putting on a new pair of gloves. She removed the bordered gauze dressing from the resident's right lower leg. She cleaned the wound with wound cleanser. She applied calcium alginate collagen to the wound and covered it with the bordered gauze dressing. She removed her gloves. She donned new gloves and removed the bordered gauze dressing from the resident's left heel. She did not perform hand hygiene between the glove changes. She discarded the dressing and said this dressing is for protection only. She removed her gloves and discarded them. She did not perform hand hygiene after removing her gloves. In an interview with LVN A on 12/11/12025 at 1:47 PM, she reported that she currently has four residents with wounds. She stated I dispose of my gloves after I take off the old dressing. I change gloves in between the old dressing and new dressing. I sanitize my hands or go straight to the bathroom and wash my hands. But I usually sanitize first and then go wash. LVN A did not acknowledge that she did not perform hand hygiene after removing her gloves during Resident #1's wound care. In an interview with the ADON on 12/11/2025 at 2:40 PM, she said that any time they touch dirty areas with their gloves, they need to change their gloves. She explained that staff should wash their hands between cleaning each wound. She stated they should clean the outside and the wound Residents Affected - Few Page 1 of 2 675971 675971 12/29/2025 Paradigm at the Oak 507 West Ave Schulenburg, TX 78956

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed would be last. It's always dirty to clean. She explained that Infection can spread if staff does not wash their hands after changing gloves or after providing care.In an interview with the DON on 12/11/2025 at 2:56 PM, he stated I expect them to change their gloves and do hand hygiene between wounds. He stated that they should follow the rule of clean to dirty. He stated staff should perform hand hygiene before and after changing gloves. He explained there are not sinks in every room. There are only two rooms in the long hall with sinks and one of them is an isolation room. The shorter hall does not have any sinks in the rooms. He stated that the staff should still use hand sanitizer gel. He stated that they should wash their hands as much as they can and reported that there is a lot of access to portable alcohol-based hand gel pumps. Record review of the facility's Hand Hygiene policy with a revision date of 6/2019 reflected 1. Hand hygiene/hand washing is done. After: A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds. H. After removal of medical/surgical or utility gloves. NOTE: Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves, e.g., clean gloves to sterile gloves, is indicated follow the specific standard of practice. However, hand washing may not be necessary until completion of the procedure. If glove hands become contaminated as gloves are changed hands can be washed. Contact with a patient's/resident's intact skin (e.g. taking a pulse or blood pressure, performing physical examinations, lifting the patient/resident in bed. Further review of page 4 of the Hand Hygiene policy procedures reflected 2. Wash Hands. C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Record review of the facility's Infection Control Program policy with a revision date of 6/2019 reflected the Major activities of the Infection Control Program: Surveillance of Infections with Implementation of Control Measures and Prevention of Infections.Prevention of spread of infections is accomplished by use of hand hygiene, standard precaution, transmission-based precautions and other barriers. 675971 Page 2 of 2