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 (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 3 Event ID: 675319 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 675319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444 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)