Health inspection·November 15, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the interdisciplinary team failed to review and revise after each COVID 19 Change of Condition assessment two (Residents #2 and #4) of eight residents reviewed for care plans. The facility failed to follow their protocol to update Residents #2 and #4's Care Plans to include acute COVID care plans due to Contact Isolation Precautions for COVID 19. This failure could place residents at risk of not receiving individualized care for their medical conditions, which could cause an increase in spreading infectious diseases and result in the resident's decline in health, mental status, and psycho-social well-being. Findings included: Record review of Resident #2's Order Summary Report dated 11/15/23 revealed An [AGE] year-old male who admitted [DATE] with diagnoses Type 2 diabetes, Mild cognitive impairment, generalized anxiety disorder, insomnia. On 11/14/23 the following orders were added: Resident require strict isolation COVID positive status in a double occupancy room. All therapy and treatment are to be provided in the room. All meals are to be served in the room. And order dated 11/14/23: COVID Assessment to be completed . Record review of Resident #2's Care plan date initiated 11/14/23 and completed by MDS Coordinator revealed, Problem - Acute Care Plan COVID 19 infection .I require care and isolation precautions specifically related to active COVID 19 infection dated 11/14/23 for the Goals and Interventions . Record review of Resident #2's Change in Condition assessment dated [DATE] completed by LVN D revealed, The symptom/sign/change I'm calling about is Positive COVID 19 .This started 11/06/23 .Things that make the condition worse are N/A .Request: COVID isolation .New order Paxlovid. Record review of Resident #4's Order Summary Report dated 11/15/23 by ADON J revealed, A [AGE] year-old female who admitted [DATE] with diagnoses Dementia, mood disturbance and anxiety, dysphagia (swallowing difficulty). On 11/14/23 the following new orders were added: Resident requires strict isolation COVID positive status in a double occupancy room. All therapy and treatment are to be provided in the room. All meals are to be served in the room. And order dated 11/14/23: COVID Assessment to be completed . Record review of Resident #4's Care Plan date initiated by the MDS Coordinator on 11/06/23 and Page 1 of 12 675995 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revised on 11/14/23 revealed, Problem: Acute Care plan COVID 19 infection .I require care and isolation precautions specifically related to active COVID 19 infection and on 11/14/23 the goals and intervention were added. Record review of Resident #4's Change in condition assessment dated [DATE] by ADON J revealed, The sign, symptom, change I'm calling about is Positive COVID Test .this started 11/06/23 .this has stayed the same since it started .Request: Protocol for COVID .No new orders. Observation on 11/14/23 at 10:43 am, outside Resident #2's room door, revealed contact isolation precautions in place. There was a PPE bin and sign on the door on how to use PPE. Observation on 11/14/23 at 11:10 am, outside Resident #4's room door had contact isolation precautions in place. There was a PPE bin and sign on the door on how to use PPE. Interview on 11/15/23 at 12:39 pm, LVN B stated they had four residents who were COVID positive that were located on the 500 hall. She stated care plans were supposed to help them know what needed to be done for each resident that was specific for each person. Interview on 11/15/23 at 4:23 pm, MDS Coordinator stated there should have been an acute COVID 19 care plan with contact isolation precautions in the resident's records for their COVID 19 positive residents. She stated the DON, ADON/IP A or floor nurses usually did the acute COVID 19 Care plans and she said she did the comprehensive and quarterly assessments. She stated she reviewed the acute COVID 19 Care Plans the nurses did because sometimes they did not fill them out correctly. She stated the DON was responsible for ensuring the care plans were accurate. She stated if the Care plan were not accurate the resident may not receive their plan of care which could cause the resident harm. Interview on 11/15/23 at 4:51 pm, the ADON/IP A stated she was not sure, but Residents #2 and #4 were COVID 19 positive on 11/06/23. She stated yesterday (11/14/23), she did an audit and checked the resident's progress notes, care plans, and doctor orders and assessments and they were up to date and in their records. She stated she was not aware their Doctors orders for contact isolation and acute COVID 19 care plans were just done yesterday (11/14/23) and was not sure who updated their records. She stated she did her audit yesterday (11/14/23) because the HHSC Surveyor had asked for these residents records. She stated once the residents were diagnosed with COVID 19, the Charge Nurses needed to do a COVID 19 assessment and call the resident's Doctor's for contact isolation orders and complete the acute COVID 19 care plans. She stated the MDS Coordinator was responsible for ensuring the resident's care plans were accurate and the DON was ultimately responsible for the care plans' accuracy. She stated the resident's care plans were used to assist the staff with how to care for the residents and was not sure how it could affect the residents if their Doctor's orders and care plans were not accurate. Interview on 11/15/23 at 5:13 pm, the MDS Coordinator stated after she reviewed of the resident's records, Residents #2 and #4 were diagnosed with COVID 19 on 11/06/23 but their Doctor's orders for contact isolation due to COVID 19 started on 11/14/23 by ADON/IP A. She stated she added Residents #2 and #4's acute COVID 19 with contact isolation care plans on 11/14/23. She stated she started looking in the residents' care plans yesterday 11/14/23 for accuracy and added the floor nurses were not experts which was why she had to ensure the care plans were accurate. She stated she was out on leave for two weeks for a family matter and that was why the acute COVID 19 Care plans were maybe not updated. 675995 Page 2 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/15/23 at 5:46 pm, the DON stated the resident's acute COVID 19 care plans had probably not been done because their MDS Coordinator was out sick and there was no one filling in for her. She stated it had been a little bit challenging what they should have done to navigate through the COVID 19 processes. She stated the acute COVID 19 care plans were not completed until yesterday 11/14/23 and added she was responsible for ensuring the care plans were accurate. She stated her expectation was for all care plans to be done upon admission and change of condition. Interview on 11/15/23 at 6:05 pm, the Administrator stated she was not aware Residents #2 and #4 did not have acute COVID 19 care plans, COVID diagnoses, and doctor orders for contact isolation not been added to their medical records until yesterday 11/14/23. She stated her expectations for care plans and doctor's orders for contact isolation due to COVID 19 was to be completed as the resident was diagnosed. Record review of the facility's undated Positive Resident in the facility Protocol, Revealed: No COVID 19 positive residents since 11/07/23 . (check marked) Place PPE Bins that include gown, gloves, N95, eye protection at the entrance of each room who is on the warm or hot zone .Documentation: (not check marked) Document positive results in PCC for all residents .Add COVID 19 for all positive residents .Add acute care plans for COVID 19 precautions for all positive and exposed residents . Record review of the facility's Care Plan Policy was not completed because the facility did not provide it, after it was requested on 11/15/23 at 5:18 pm and 11/16/23 at 9:32 am. 675995 Page 3 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete and accurately documented for 4 (Residents #1, #2, #3 and #4) of eight residents reviewed for administration. 1. The facility failed to ensure Residents #1 ,#2, #3 and #4 had physician orders for contact isolation due to their COVID 19 diagnoses in their medical records. 2. The facility failed to ensure Residents #1, #2, #3 and #4's medical records were updated to include their COVID 19 diagnoses. 3. The facility failed to have acute Care plans for Residents #2 and #4 in their Medical records. These failures could affect residents by placing them at risk of not getting proper treatment, care and services which could result in increased chance of cross contamination and decrease in their health and psycho-social well-being. Findings included: Record review of Resident #1's Order Summary report dated 11/15/23 revealed a [AGE] year old female who admitted [DATE] with diagnoses Mental Disorder, Acute Bronchitis, postnasal drip . on 11/14/23 orders added: Resident requires strict isolation COVID positive status in a double occupancy room. All therapy and treatment are to be provided in the room. All meals are to be served in the room and order dated 11/14/23 COVID Assessment to be completed Record review of Resident #1's Care Plan date initiated 11/14/23 by unknown author revealed, 11/06/23 - I have tested positive for COVID 19 and the goals and intervention sections were blank. Record review of Resident #1's Change in condition Assessment completed by ADON/IP A dated 11/06/23 revealed, The symptom/sign/change I'm calling about is - COVID 19 positive .exposed to COVID 11/02/23 .This has stayed the same since it started .Request: COVID 19 protocol and monitor vital signs and observe . Record review of Resident #2's Order Summary Report dated 11/15/23 revealed an [AGE] year-old male who admitted [DATE] with diagnoses Type 2 diabetes, Mild cognitive impairment, generalized anxiety disorder, insomnia and on 11/14/23 orders added: Resident requires strict isolation COVID positive status in a double occupancy room. All therapy and treatment are to be provided in the room. All meals are to be served in the room. And order dated 11/14/23: COVID Assessment to be completed Record review of Resident #2's Care plan date initiated 11/14/23 and completed by MDS Coordinator revealed, Problem - Acute Care Plan COVID 19 infection .I require care and isolation precautions specifically related to active COVID 19 infection and dated 11/14/23 for the Goals and Interventions . Record review of Resident #2's Change in Condition assessment dated [DATE] completed by LVN D revealed, The symptom/sign/change I'm calling about is Positive COVID 19 .This started 11/06/23 .Things that make the condition worse are N/A .Request: COVID isolation .New order Paxlovid. 675995 Page 4 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's Order Summary Report 11/15/23 revealed an [AGE] year-old female who admitted [DATE] with diagnoses with dementia, mood disturbance, Dysphagia .order dated 11/14/23 for: Resident requires strict isolation COVID positive status in a double occupancy room. All therapy and treatment are to be provided in the room. All meals are to be served in the room. And order dated 11/14/23: COVID Assessment to be completed Residents Affected - Some Record review of Resident #3's Care plan Date initiated 11/04/23 and date revised 11/14/23 revealed, acute care plan: COVID 19 Infection I require care and isolation precautions specifically related to active COVID 19 infection. Date initiated: 11/14/23 for the Goals and interventions. Record review of Resident #3's Change in condition Assessment by LVN D dated 11/06/23 revealed, The symptom/sign/change I'm calling about is Positive Covid test .This started 11/06/23 .This has gotten (blank) .Request: Isolation COVID . New order for Paxlovid . Record review of Resident #4's Order Summary Report dated 11/15/23 by ADON J revealed, a [AGE] year-old female who admitted [DATE] with diagnoses Dementia, mood disturbance and anxiety, dysphagia and on 11/14/23 new orders: Resident requires strict isolation COVID positive status in a double occupancy room. All therapy and treatment are to be provided in the room. All meals are to be served in the room. And order dated 11/14/23: COVID Assessment to be completed Record review of Resident #4's Care Plan date initiated by the MDS Coordinator on 11/06/23 and revised on 11/14/23 revealed, Problem: acute care plan COVID 19 infection .I require care and isolation precautions specifically related to active COVID 19 infection and on 11/14/23 the goals and intervention were added. Record review of Resident #4's Change in condition assessment dated [DATE] by ADON J revealed, The sign, symptom, change I'm calling about is Positive COVID Test .this started 11/06/23 .this has stayed the same since it started .Request: Protocol for COVID .No new orders. Observation on 11/14/23 at 10:44 am, outside Resident #1's, room door had contact isolation precautions in place, there was a PPE bin a sign on the door on how to use PPE. Observation on 11/14/23 at 10:43 am, outside Resident #2's room door had contact isolation precautions in place, there was a PPE bin a sign on the door on how to use PPE. Observation on 11/14/23 at 10:43 am, outside Resident #3's room door had contact isolation precautions in place, there was a PPE bin a sign on the door on how to use PPE. Observation on 11/14/23 at 11:10 am, outside Resident #4's room door had contact isolation precautions in place, there was a PPE bin a sign on the door on how to use PPE. Interview on 11/14/23 at 4:47 pm, LVN C stated if he were to get a COVID 19 positive resident, he would keep them on contact isolation, notify the doctor about the resident's symptoms, and get orders to keep the resident safe and notify the resident's family. He stated the residents needed to have orders for contact isolation to prevent the spread of COVID 19. Interview on 11/14/23 at 5:16 pm, LVN D stated they had five residents that were COVID 19 positive. She stated once the residents were confirmed positive, they notified the residents Dr., family and DON. She stated the nurses needed the Doctor's order for directions on what treatment to start the 675995 Page 5 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident on, and to put them on contact isolation immediately and get a Doctor's order for contact isolation. She stated she was unaware the COVID 19 positive residents did not have contact isolations orders. She stated it was important for the COVID 19 positive residents to have contact isolation precautions in place so that everyone took the proper steps to prevent spreading the infection. Interview on 11/15/23 at 12:39 pm, LVN B stated they had 4 residents who were COVID 19 positive that were located on the 500 hall. She stated care plans were supposed to help them know what needed to be done for each resident that was specific for each person. Interview on 11/15/23 at 1:27 pm, LVN E stated whenever a resident tested positive they were to call the resident's Doctor, DON, and Administrator. She stated they had to put the protocol in place for them to be in contact isolation by getting a Doctor's order by contacting the resident's Doctor. immediately after a resident tested positive for COVID 19. She stated care plans were used to know how to care for the residents and added they was supposed to follow the Doctor's orders and the facility's protocol. She stated if the COVID 19 positive resident had no order for contact isolation, it could cause the infection to spread if it was not in the resident's records. Interview on 11/15/23 at 1:50 pm, LVN F stated once a resident was COVID 19 positive, the Doctor. was notified immediately to get directions to follow the go by the facility's COVID 19 protocol. He stated this included placing the resident on contact isolation, notifying the resident's responsible party/family member and putting out the PPE bins and signs. He stated the significance of Doctor's orders were to save the patient and coordinate care, and if there were no orders for contact isolation could increase the resident's chance of getting COVID 19. He stated the resident's care plans told the staff how to take care of the resident and added the residents should have had a care plan for COVID and contact isolation. Interview on 11/15/23 at 4:41 pm, the Medical Records Director stated they currently had some positive COVID 19 residents and there were no issues with their records missing anything. She stated the positive COVID 19 residents had care plans and the physician's orders, so that the nurses could follow-up with the residents care and to treat the residents appropriately. She stated if those records were not in place, it could be fatal to a resident because the nurses would not adequately be able to treat the residents if the information is not there. She stated she was responsible for making sure the records were in their profiles, but the ADONs and DON were responsible for reviewing the orders for accuracy. Interview on 11/15/23 at 4:51 pm, the ADON/IP A stated she was not for sure but Residents #2 and #4 was COVID 19 positive 11/06/23 and Residents #1 and #3 was COVID 19 positive on 11/07/23. She stated yesterday (11/14/23) she did an audit and checked these four resident's progress notes, care plans and Dr. Orders and assessments and they were up to date and in their records. She stated she was not aware their Dr. orders for contact isolation and acute COVID 19 care plans was just done yesterday (11/14/23) and was not sure who updated their records. She stated she did her audit yesterday (11/14/23) because the HHSC Surveyor had asked for these residents records. She stated said once the residents were diagnosed with COVID 19, the Charge Nurses needed to do a COVID 19 assessment and call the resident's Doctor. for contact isolation orders and complete the acute COVID 19 care plans. She stated the MDS Coordinator was responsible for ensuring the resident's care plans were accurate and the DON was ultimately responsible for the care plans' accuracy. She stated the resident's care plans were used to assist the staff with how to care for the residents, but she was not sure how it could affect the residents if their Doctor's orders and care plans were not accurate. 675995 Page 6 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 11/15/23 at 5:13 pm, the MDS Coordinator stated after she reviewed the resident's records, Residents #2 and #4 were diagnosed with COVID 19 on 11/06/23 but there Dr.'s orders for contact isolation due to COVID 19 started on 11/14/23 by ADON/IP A. She stated Residents #2 and #4's acute COVID 19 with contact isolation care plans were completed on 11/14/23. She stated she started looking in the residents' care plans yesterday 11/14/23 for accuracy and added the floor nurses were not experts which was why she had to ensure the care plans were accurate. She stated she was out on leave for 2 weeks for family matter and that was why the acute COVID 19 Care plans were not updated. Interview on 11/15/23 at 5:46 pm, the DON stated the resident's acute COVID 19 care plans were probably not done because their MDS Coordinator was out sick and there was no one filling in for her. She stated it had been a little bit challenging what they should do to navigate through the COVID 19 processes. She stated the acute COVID 19 care plans were not completed until yesterday 11/14/23 and added she was responsible for ensuring the care plans were accurate. She stated her expectations for all care plans to be done upon admission and change of condition. Interview on 11/15/23 at 6:05 pm, the Administrator stated she was not aware the Residents #1, #2, #3 and #4's acute COVID 19 care plans, COVID diagnoses, and doctor orders for contact isolation had not been added to their medical records until yesterday 11/14/23. She stated her expectations for care plans and doctor's orders for contact isolation due to COVID 19 was to be completed as the resident was diagnosed. Record review of the facility's Positive Resident in the facility Protocol undated, Revealed: No COVID 19 positive residents since 11/07/23 . (check marked) Place PPE Bins that include gown, gloves N95, eye protection at the entrance of each room who is on the warm or hot zone .Documentation: (Was not checked marked) Document positive results in PCC for all residents .Add COVID 19 for all positive residents .Add acute care plans for COVID 19 precautions for all positive and exposed residents . The facility's Medical Records Policy was not completed because the facility did not provide it, after it was requested on 11/15/23 at 5:18 pm and 11/16/23 at 9:32 am. 675995 Page 7 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 one (Station #2) of two nurses stations and one Resident's room (#512) of four resident's rooms and one (Front entrance area) of one front entrance area reviewed for infection control. Residents Affected - Some The facility failed to ensure CNA G wore an N95 facemask when she walked from the 500 hall, where COVID 19 residents' rooms were. The facility failed to ensure LVN E wore an N95 facemask appropriately while she was standing at the 500 hall nurses station #2. The facility failed to ensure Floor Tech H had on appropriate PPE on when he was in a Resident a resident's room who was diagnosed with COVID 19 and on Contact Isolation Precautions. The facility failed to ensure Housekeeper I did not keep her personal drink on the housekeeping cart while cleaning the resident's rooms. The facility failed to post notification of their Positive COVID 19 status at the front entrance of the facility for visitors to be informed of their COVID 19 status. The facility failed to have N95 mask available for the visitors and the facility only had surgical masks at the sign in table. These failures could place residents at risk of getting COVID 19, which could result in respiratory and digestive illnesses causing a decline in their physical function and psycho-social well-being. Findings included: Observation on 11/14/23 at 8:53 am revealed there were no positive COVID 19 signs on the front entrance door or anywhere else in the front foyer of the facility. On the sign-in table, there was a 'COVID 19 signs and symptoms' and a 'masks required' postings. And there were blue surgical masks on the table. Observation on 11/14/23 at 9:10 am revealed CNA G did not have on a N95 mask and quickly grabbed one and put it on her face as she was standing at Nursing Station #2. Observation on 11/14/23 at 10:44 am, outside Resident #1's room door, revealed contact isolation precautions in place. There was a PPE bin and a sign on the door on how to use PPE. Observation on 11/14/23 at 10:43 am, outside Resident #2's room door, revealed contact isolation precautions in place. There was a PPE bin and sign on the door on how to use PPE. Observation on 11/14/23 at 10:43 am, outside Resident #3's room door, revealed contact isolation precautions in place. There was a PPE bin and sign on the door on how to use PPE. Observation on 11/14/23 at 11:10 am, outside Resident #4's room door, revealed contact isolation 675995 Page 8 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0880 precautions in place. There was a PPE bin and sign on the door on how to use PPE. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 11/15/23 at 9:08 am, revealed LVN E was walking to the 500 hall nurses station #2 and her N95 face mask was underneath her chin, exposing her nose and mouth. She stated she had just come from the hydration room for a drink and forgot to put her face mask back up. Residents Affected - Some Observation and interview on 11/15/23 at 9:10 am revealed Floor Tech H was in Resident #3's room with a broom in his hand and his N95 mask was under his chin. He did not have on any other PPE. He was talking to a family member in the room and Resident #3 was also in the room. He stated he did not notice the Contact Isolation sign on the door or the PPE bin outside Resident #3's door. He stated he had just pulled his N95 mask down to talk to the resident's family for the family member to hear him better. He stated he was just running in and out of the room and was not assigned to clean this room. He stated not wearing PPE in contact isolation rooms could cause him or the resident to catch anything. Observation and interview on 11/15/23 at 9:55 am revealed Housekeeper I was cleaning a resident's room on the cold zone hall 500 and she had her peach colored thermos on top of the housekeeping cart and next to the trash, mop and broom. She stated she usually kept her drink in the bottom compartment of her housekeeping cart. Record review of the facility's Positive Resident in the facility Protocol undated, Revealed: No COVID 19 positive residents since 11/07/23 .(check marked) Place PPE Bins that include gown, gloves N95, eye protection at the entrance of each room who is on the warm or hot zone .Continually monitor staff and proper PPE use .clean and disinfect patient rooms when a positive case vacates the room. Interview on 11/14/23 1:35 am, the Activities Director revealed they had 8 residents that were COVID 19 positive. She stated the department heads were notified of their COVID 19 positive cases via text and in their standup meetings by the DON. She stated she had not seen any COVID 19 notice signage in the front lobby or front door for visitors to know they had COVID cases and said they used to have the COVID 19 sign up last year when they had positive COVID 19 cases. She stated there should be a notice for the visitors to be given a choice to come inside the facility or not. She stated if the visitors were not aware of this facility's COVID 19 they could bring covid to the building or get exposed to COVID 19. Interview on 11/14/23 at 12:20 pm, Receptionist G stated they had three COVID 19 cases in the building and there had not been a COVID 19 notice at the entrance of the building for the past few weeks and she was not sure why. She stated about an hour ago today (11/14/13) the Administrator told her to put a COVID 19 sign on the table next to the sign-in sheets. She stated they should have had the COVID 19 signage up because it could affect the residents if their visitors got exposed to COVID 19 if the facility were not taking the proper measures with PPE and hand hygiene usage, and could give it to the residents. Interview on 11/14/23 at 12:15 pm, the MDS Coordinator stated they had seven residents who were COVID 19 positive and have had COVID 19 cases for about three weeks. She stated she was not sure if they had a COVID 19 positive sign at the front entrance, informing visitors of their positive COVID 19 cases. She stated the visitors could be exposed to COVID 19 if they were not notified about the COVID 19 cases. Observation on 11/14/23 at 12:20 pm revealed the Notice of positive COVID 19 cases was posted at 675995 Page 9 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the sign-in table at the front entrance of the facility, along with the requirement to wear a mask but the signage about the signs and symptoms of COVID 19 was missing. Interview and observation on 11/14/23 at 12:32 pm revealed the Administrator stated they had 4 COVID 19 cases and was not aware the positive COVID 19 posting was missing. She stated the COVID 19 notice was posted with another sign for visitors to wear a mask was up also at the sign-in table. After going to front entrance, the Administrator started asking What happened to the COVID 19 signs and symptoms notice and would have to ask if anyone knew what happened to it. She stated the reason why the positive COVID 19 notice was needed at the front entrance door was to make sure visitors had a choice to come inside the facility or not. She stated the IP was responsible for ensuring the COVID 19 positive cases signage was posted for the visitors to see. She stated if there was no COVID 19 notice posted visitors could get exposed. She stated this facility had N95 masks available if the visitors asked for them that were stored in her office. Observation on 11/14/23 at 12:39 pm, A male contracted vendor looked at the COVID 19 notice and asked the Administrator did they have COVID 19 cases, and she responded yes. He then he asked the Administrator for a N95 mask the facility only had the blue surgical masks on the sign - in desk. Interview on 11/14/23 at 1:10 pm, the ADON/IP A stated they had COVID 19 cases at this facility and the last time she noticed the COVID 19 sign at the front entrance was yesterday 11/14/23. She stated it had always been in the front lobby along with the COVID 19 signs and symptoms posting. She stated the COVID 19 positive sign should be up to notify visitors and vendor they have positive covid cases and said she was not aware it was missing from the front entrance. She stated their visitors should know they had COVID 19 cases for everyone's safety and said the visitors had a risk of exposure if they were not aware they had COVID 19 cases. She stated she was responsible for ensuring the COVID 19 notices were in place and PPE was being used appropriately. She stated the receptionist and nurses sent mail outs notifying the resident's and family members. She stated the DON and herself notified the staff about their COVID 19 status and ensured the staff wore the proper PPE. Interview on 11/14/23 at 1:55 pm, the Human Resources Director stated they had COVID 19 cases, and she was the person who saw the positive COVID 19 cases notice on Nurses station #1. She stated she was not sure how long it had been down there or who moved it from the front entrance and stated she moved the COVID 19 signs and symptoms sign to the resident sitting area. She stated she was not sure who was responsible for ensuring the COVID 19 sign was posted at the entrance door and did not notice it was missing until she went to station #1 then she took it up to the front entrance. She stated the COVID 19 notice should be in the front entrance for precautionary reasons to prevent the spread of the disease. She stated she was reprimanded by the Administrator for moving the COVID 19 signs and symptoms sign. Interview on 11/15/23 at 12:00 pm, DON stated she was not aware Floor Tech H was in Resident #3's room who was on contact isolation room without all the proper PPE. She stated the housekeeper should not store their personal drinks on the housekeeping carts and the nurse should all be wearing N95 mask in the commons areas. She stated she was going to talk to him immediately and said he should have known to put on PPE before entering the contact isolation room. She stated she would do Inservice trainings with all staff to prevent this from happening again. She stated they had seven COVID 19 positive residents and she was not aware of the COVID 19 cases sign being missing from the entrance door. She stated the COVID 19 sign needed to be up posted at the front entrance to give their visitors the opportunity to protect themselves to not enter the facility. She stated ADON/IP was responsible for ensuring the COVID 19 notice was posted up front but said ultimately it was her responsibility 675995 Page 10 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0880 to ensure the COVID 19 cases sign was up. Level of Harm - Minimal harm or potential for actual harm Interview on 11/15/23 at 12:39 pm, LVN B stated they had four COVID 19 positive residents on the 500 hall and added when a resident tested COVID 19 positive they needed to wear all PPE such as the N95, gloves, gown, and face shield. She stated when a resident tested COVID positive, they had to get an order for contact isolation immediately after to ensure that everyone followed the orders to prevent the disease from spreading. Residents Affected - Some Interview on 11/15/23 at 1:27 pm, LVN E stated they had five COVID 19 positive residents. She stated whenever a resident tested COVID 19 positive, they called the resident's doctor, DON, and Administrator then put the protocol in place for them to be on contact isolation. Interview on 11/15/23 at 5:46 pm, the DON stated they re-educated all staff including Floor Tech H, Housekeeper I and LVN E about Infection Control practices and ensuring they had on the proper PPE. Interview on 11/15/23 at 6:05 am, the Administrator stated she was not sure why the Receptionist and Human Resources Director both said they put the COVID 19 positive cases sign on the front entrance table yesterday (11/14/23). She stated she would talk to the IP to ensure there would be no further issues with the postings being displayed in the front lobby and door. She stated yesterday 11/14/23, she put the COVID 19 cases notice on the front door outside as well. Record review of the Infection Control Training dated 11/15/23 revealed, Topic: Wearing Mask while in the facility and Wearing PPE when entering isolation rooms was conducted by ADON/IP A and had 42 staff signatures. Record Review of the COVID Positive Resident listing dated 11/13/23 revealed Residents #1, #2, #3 and #4 on the list. Record review of the Aerosol contact precautions sign revealed, In addition to standard precautions .only essential personnel should enter this room .If you have questions ask clinical staff .Everyone must: including visitors, doctors & staff: clean hands when entering and leaving room .use respirator, mask for visitors, wear eye protection and gown and glove at door .Keep door close Record review of the Facility's Infection Control plan: Overview policy updated 03/2023 revealed, Infection Control - The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection .Preventing spread of infection- The facility will require staff to Donn and Doff PPE before and after contact with resident who needs isolation to prevent the spread of infection to others in the facility . Record review of the Mandatory COVID 19 Vaccination Policy undated, .HCP will be required to: wear a facility approved respirator (K95 or higher) at all times, even in cubicles or private offices. They are to be strictly worn to enter and remain on premises Record review of the CDC COVID 19 Infection Control Guidance dated 05/08/23 revealed, Establish a process to identify and manage individuals with suspected or confirmed SARS - COVID 19 infection: Ensure everyone is aware of the IPC practices at the facility .Post visual alerts (signs, posters) at the entrance and strategic areas (waiting areas) .establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the three 675995 Page 11 of 12 675995 11/15/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0880 Level of Harm - Minimal harm or potential for actual harm criteria: 1. a positive viral test for SARS-CoV-2 .2. Symptoms of COVID 19 or 3. Close contact with someone with SARS-Cov-2 infection (for patients and visitors) or a higher risk exposure for healthcare personnel .Provide guidance (posted signs at entrances) about recommended actions for patients and visitors with any of the above three criteria .Indoor visitation during outbreak response: Visitors should be counseled about their potential to be exposed to SARS-CoV-in the facility . Residents Affected - Some 675995 Page 12 of 12