Health inspection·April 14, 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 to 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 and failed to notify HHSC as part of their infection prevention and control program when # residents and # staff, tested positive for COVID-19 between 8/3/22 and 9/12/22 for 1 of 1 resident (Resident #1) and 5 of 5 staff (DA A, PTA, Transport, HK A, and Restorative Aide reviewed for infection control. Residents Affected - Few The facility failed to notify HHSC when 1 resident and 5 staff tested positive for COVID-19 between 8/3/22 and 9/12/22 after the facility approximately three weeks with no COVID-19 positive residents or staff (the last COVID-19 positive case was reported to HHSC on 5/16/22). This could place all COVID-19 negative residents at risk of being expose to the virus. Findings included Record review of TULIP on 4/12/23 at 10:00 a.m. revealed no self-reported incidents from the facility in August 2022 and none regarding new COVID-19 positive cases at the facility since 5/16/22. Record review of the facility's COVID-19 Positive Tracking and Staff-COVID-19 Positive tracking logs for August 2022 revealed the following: - On 8/4/22, Dietary Aide A tested positive for COVID-19. - On 8/8 /22, Physical Therapy Assistant tested positive for COVID-19. - On 8/17/22, Transport staff member tested positive for COVID-19. - On 8/21/22, Housekeeper A tested positive for COVID-19 - On 9/9/22, Restorative Aide tested positive for COVID-19 - On 9/12/22, Resident #1 tested positive for COVID-19. Record review of Resident #1's admission Record on 4/14/23 at 12:46 p.m. revealed she was a [AGE] year old female who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with Page 1 of 2 676223 676223 04/14/2023 Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the following diagnoses chronic obstructive pulmonary disease ( a group of lung diseases that block airflow and make it difficult to breath), diabetes mellitus type II (Chronic condition that affects the way the body processes blood sugar (glucose), cough (expel air from the lungs with a sudden sharp sound), and asthma (a respiratory condition marked by spasms of the lungs causing difficulty in breathing). Record review of Resident #1's progress notes on 4/14/23 at 1:03 p.m. dated 9/11/2022 revealed in part: . Resident continues on contact isolation due to a positive covid rapid test . Interview with the DON on 4/14/23 at 12:22 p.m., who said that she was employed during this time and began employment in June of 2021. She stated the Former Administrator would be responsible for reporting COVID-19. She said that the cases were supposed to be reported if over 14-days, meaning they could not go more than 14 days without reporting but if the cases are in between the 14-day window they did not have to report them. The DON also said cases should have been reported within 24 hours of the first positive case. She said she was unaware that the COVID cases in August of 2022, had not been reported by the Former Administrator, because it was her job. The DON said it was not her job to report the COVID-19 cases. Interview with the Administrator on 4/14/23 at 12:34 p.m., he stated he became the Administrator on 8/8/22. He said that he thought the incident had already been reported to HHSC. He said the Former Administrator would have been responsible for reporting COVID-19 case/s and should have reported the case on 8/4/22 within 24 hours of the first positive case. He said he did not have a facility policy and procedure regarding infection control available. He said he did not have a specific policy and procedure regarding reporting, but he used the HHS provider letter for reference and guidance on reporting. Interview with the Infection Preventionist on 4/14/23 at 12:36 p.m., he stated he began employment on 6/25/12. He stated the Former Administrator would have been and was responsible for reporting COVID-19 cases and that it should have been reported within 24 hours of the first positive case. He said that he did not and had never been responsible for reporting COVID -19 cases for the facility. Record review of Long-Term Care Regulation Provider Letter with a Date Issued: Revised January 19, 2023. 1.0 Subject and Purpose This letter describes the information that a provider must include in an initial reportable incident report made to HHSC Complaint and Incident Intake .2.0 Policy Details & Provider Responsibilities .A provider must: report reportable incidents to CII .ensure a thorough investigation is conducted and documented in the PIR and submit the PIR to CII within the regulatory timeframe that applies to the provider type The provider must submit the PIR within the applicable required time frame as follows: 5 working days for an .NF or skilled NF 676223 Page 2 of 2