Health inspection·November 15, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases was established and maintained for infection control related to COVID-19 (a virus that is spread from person to person causing mild to severe respiratory symptoms) for 16 of 18 residents reviewed. Residents Affected - Some Multiple asymptomatic residents tested positive for COVID-19 after dietary staff tested positive for COVID-19, by not taking preventative measures. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19. Findings include: Record review of Resident #1's face sheet dated 10/15/23 revealed an admission date of 6/14/23 with a BIMS of 6 and diagnoses which included: Dementia, kidney disease, and hypertension. Record review of Resident #2's face sheet dated 10/15/23 revealed an admission date of 1/28/22 with a BIMS of 5 and diagnoses which included: heat disease, kidney disease, dementia, and type 2 diabetes. Record review of Resident #3's face sheet dated 10/15/23 revealed an admission date of 11/14/20 with a BIMS of 6 and diagnoses which included: Anemia, type 2 diabetes, osteomyelitis. Record review of Resident #4's face sheet dated 10/15/23 revealed an admission date of 10/18/21 with a BIMS of 11 and diagnoses which included: anemia, heart failure, and shortness of breath. Record review of Resident #5's face sheet dated 10/15/23 revealed an admission date of 1/10/23 with a BIMS of 14 and diagnoses which included: multiple sclerosis, muscle weakness, and anorexia. Record review of Resident #6's face sheet dated 10/15/23 revealed an admission date of 3/10/23 with a BIMS of 6 and diagnoses which included: necrosis of amputation stump, cellulitis of left lower limb, and peripheral vascular disease. Record review of Resident #7's face sheet dated 10/15/23 revealed an admission date of 8/17/23 with a BIMS of 6 and diagnoses which included: fall from one level to another, altered mental status, and hypothyroidism. Record review of Resident #8's face sheet dated 10/15/23 revealed an admission date of 4/1/22 with Page 1 of 3 675319 675319 11/15/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0880 a BIMS of 12 and diagnoses which included: Heart failure, edema, and urinary tract infection. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9's face sheet dated 10/15/23 revealed an admission date of 5/12/23 with a BIMS of 7 and diagnoses which included: fracture to neck, history of falling, and muscle wasting. Residents Affected - Some Record review of Resident #10's face sheet dated 10/15/23 revealed an admission date of 10/7/20 with a BIMS of 14 and diagnoses which included: heart failure, hypertension, and anxiety disorder. Record review of Resident #11's face sheet dated 10/15/23 revealed an admission date of 1/16/23 with a BIMS of 4 and diagnoses which included: heart disease, weakness, hypertension. Record review of Resident #12's face sheet dated 10/15/23 revealed an admission date of 8/28/23 with a BIMS of 4 and diagnoses which included: type 2 diabetes, hypertension, and dementia. Record review of Resident #13's face sheet dated 10/15/23 revealed an admission date of 10/18/23 with a BIMS of 4 and diagnoses which included: heart failure, type 2 diabetes, and hypertension. Record review of Resident #14's face sheet dated 10/15/23 revealed an admission date of 5/10/21 with a BIMS of 3 and diagnoses which included: muscle wasting, dementia, hypothyroidism. Record review of Resident #15's face sheet dated 10/15/23 revealed an admission date of 6/6/23 with a BIMS of 13 and diagnoses which included: dementia, weakness, and Alzheimer's disease. Record review of Resident #16's face sheet dated 10/15/23 revealed an admission date of 4/26/22 with a BIMS of 5 and diagnoses which included: Dementia, Alzheimer's disease, and anxiety disorder. Record review of Facilities Infection Control Employee Testing: 11/1/23 DM A tested positive for covid-19 11/6/23 DA B tested positive for covid-19 11/6/23 DA C tested positive for covid-19 11/9/23 DA D tested positive for covid-19 11/10/23 2-CNA's tested positive the facility started testing all of the residents which at this time, 16 resident came back positive. Record review of Facilities Covid tracking of all positive residents dated 11/10/23 revealed all residents were asymptomatic, with none of the residents having to be sent out of the facility. During an interview, on 11/15/23 at 12:25 pm, the DON stated that she is the infection preventionist and based on the facility's policy they look at testing residents through root cause analysis and see if an employee had been in direct contract such as an aide or nurse; then those residents would be tested. She stated that when the Dietary Manager did test positive, she did not believe residents needed to be tested because they should have been following proper hand hygiene and cooking the food to the correct temperature resulting in not spreading to the infection to the residents. She 675319 Page 2 of 3 675319 11/15/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0880 Level of Harm - Minimal harm or potential for actual harm stated that when the two other dietary employees tested positive that were also kitchen, she should have probably started to test residents at that point, but once again, did not because they were not direct care employees. Attempted to contact the Medical Director on 11/15/23 at 11:45 AM, no answer, left message. Residents Affected - Some During an interview on 11/15/23 at 12:15 pm DM A stated she went to work the morning of 11/1/23 but was not feeling well. She stated after working a few hours she tested for covid-19, and it came back positive, so she went home. She stated that she was not 100% sure that residents should have been tested at that point, and it's the Administrator's call at that point. She stated that her employees started to wear masks because she tested positive. She stated that on 11/6/23 two of her employees tested positive. She stated that in her opinion, at that point, the residents should have probably been tested, but once again that is not her call to make. During an interview on 11/15/23 at 12:45 pm the ADON stated she felt they had covid-19 contained in the kitchen. She stated that 11/1/23 the manager tested positive but not until 11/6/23 did the other employees in the kitchen test positive. She stated that is why they did not test residents. During an interview on 11/15/23 at 11:15 AM the Administrator stated they had 16 covid-19 positive residents in the facility. She stated she believed based on the facility's infection control tracking; the residents got sick during their Halloween party which took place on 10/30/23. She stated the first employee tested positive on 11/1/23. She stated the employee was the dietary manager. She stated because DM A is not direct care staff, she did not test anyone except the dietary staff. Attempted to contact the Medical Director on 11/15/23 at 2:45 AM, no answer, left message. Record review on facility's outbreak control policy dated 3/2023 revealed: It is important that facility know how to recognize and contain infectious outbreaks. An outbreak is typically one or more of the following. -occurrence of three or more cases of the same infection over a month on the same unit or other defined area. 675319 Page 3 of 3