Health inspection·September 7, 2023

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 interview and record review the facility failed 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 1 of 3 residents (Resident #1) reviewed for infection control. Residents Affected - Some -The facility failed to submit a completed PIR(#419917) to the SSA within 5 working days after CNA B tested positive for COVID-19 on 04/19/2023. -The facility failed to submit a completed PIR(#422526) to the SSA within 5 working days after Resident#1 tested positive for COVID-19 on 05/04/2023. -The facility failed to submit a completed PIR(#438333) to the SSA within 5 working days after CNA C tested positive for COVID-19 on 07/20/2023. This failure could place the residents at risk of not receiving timely reporting of incidents involving allegations of infection control for a census of 84 residents. Findings included: Record review of Resident#1's face sheet dated 09/07/2023 revealed she was a [AGE] year old female admitted on [DATE] with a primary diagnoses of Encephalopathy (decrease in blood flow or oxygen to the brain). Record review of Resdient#1's Quarterly MDS dated [DATE] revealed a BIMS score of 14 that indicated the resident was cognitively intact. Record review of Resident#1's undated care plan indicated resident was a risk for S/SX of Covid-19 Including SOB, Fever, Cough and Flu Like Symptoms R/T Potential Exposure and HX of having COVID-19. Record review of TULIP revealed a submission date of 04/28/2023 for PIR# 419917 had not been uploaded. Record review of TULIP revealed a submission date of 05/12/2023 for PIR# 422526 had not been uploaded. Record review of TULIP revealed a submission date of 07/28/2023 for PIR# 438333 had not been uploaded. Page 1 of 3 676160 676160 09/07/2023 Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 09/07/2023 at 9:25am with the DON, she said that she has been designated to complete self-reported investigations and report to the SSA by the Administrator. She said that she completed the PIR's for intakes 419917, 422526, and 438333. She said that the completed investigation was submitted by email to the SSA within 5 days, she was not sure why the completed PIR's were not uploaded in the SSA database, and she did not have email confirmation that the complete PIR's were submitted. She said that completed investigation are submitted to the SSA within 5 days according to their policy on abuse and neglect to include reporting. She said that the information is shared with the Administrator and the Executive Director of Clinical Services. She said that the importance of completed investigations being sent to the SSA was the facilities regulations policy to ensure that the facility had addressed issues in a timely manner. She said that the risk to resident was a negative outcome that could cause infection spread. In an interview on 09/07/2023 at 10:30am with the Administrator, she said that she is the Abuse Coordinator but had designated the DON to complete investigations and submit to the SSA. She said that completed investigation should be submitted within 5 days. She said that the facilities Abuse and Neglect policy is used for timelines on reporting for all self-reported incidents. She said that she was not aware of there to be PIR's that had not been submitted to the SSA prior to entrance. She said that the DON said that the PIR's were submitted by email to the SSA, but the DON did not have assess to the emails after her computer stopped working. She said that she was not included on the emails. She said that the importance of completed investigations being submitted to the SSA is the regulations and the facilities policy to ensure that the facility had addressed the issue timely. She said that the risk to residents is that infection could spread. In an interview on 09/07/2023 at 9:52am with the IP, she said that she started at the facility in 2022, and she is an LVN. She said that the abuse coordinator is the Administrator, the DON was designated to complete investigations and report to the SSA, but the Administrator was the oversight. She said that completed investigations are submitted to the SSA within 5 days. She said that completed investigations should be reported to the SSA to ensure the facility had not missed something and done everything to prevent the spread of infection to other residents in the facility. In an interview on 09/07/2023 at 10:19am with ADON, she said that she started at the facility in 2012. She said that the abuse coordinator is the Administrator, the DON was designated to complete investigations and report to the SSA, but the Administrator was the oversight. She said that the facilities Abuse Investigation and Reporting policy stated that completed investigations are submitted to the SSA within 5 days. She said that completed investigations should be reported to the SSA to ensure the facility had done what is needed to prevent the spread of infection, and if the facility had not done what was needed there was a risk of infection spreading to other residents. In a phone interview on 09/07/2023 at 12:00pm with the Executive Director of Clinical Services, she said that she has worked for the corporate office for 9 years. She said that she is informed when there is a self-reported incident at the facility, and the facility should utilize the policy for Abuse Investigation and Reporting for time frames for submission of completed investigations. She said that completed investigations should be completed and submitted to the SSA within 5 days She said that the Administrator or designee should ensure that the task is completed. She said that completed investigations for infection control should be submitted to ensure that infection control policies and procedures were completed to prevent the spread of infection. Record Review of the facilities policy titled Infection Prevention and Control Program dated January 2018, read in part .6. a. Outbreak management is a process that consist of: (9) c. The medical 676160 Page 2 of 3 676160 09/07/2023 Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff will hep the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. Record Review of Number: PL 18-20 titled Incident Reporting Requirements with revised date of January 19, 2023, read in part .This letter describes the information that a provider must include in an initial reportable incident report made to HHSC Complaint and Incident Intake(CII) and in the provider investigation report (PIR) submitted to CII .A provider must submit a PIR to CII using HHSC Form 3613-A .The PIR must include all information from the initial incident report and any additional information the provider has obtained since making the initial report, including witness statements. The provider must submit the PIR within the applicable required time frame, as follows: o Five working days for .NF or skilled NF; 676160 Page 3 of 3