Health inspection·January 6, 2024

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 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 eight (Residents #1 - #8) out of 14 residents reviewed for infection control, in that: Residents Affected - Some The facility failed to: - Ensure Residents that tested positive for COVID-19 (Residents #1 - #4) were isolated from their confirmed negative roommates (Residents #5 -#8). - Ensure staff were donning CDC-recommended PPE before entering rooms of COVID-19 positive residents (Residents #1 - #4). These failures placed residents at risk of transmission and/or spread of infection which could lead to hospitalization. Findings included: Review of the facility's outbreak tracking record, on 01/05/24, reflected one resident tested positive for COVID-19 on 12/31/23, three residents tested positive on 01/04/24, and ten residents tested positive 01/05/24 (four of the ten were Residents #1 - #4). Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, cognitive communication deficit, hypertension (high blood pressure), and unspecified dementia. Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, type II diabetes , stroke, heart failure, and Alzheimer's disease (a type of dementia that damages the brain and affects memory, thinking, and behavior). Review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including hypertension, cognitive communication deficit, and muscle wasting and atrophy (wasting away). Review of Resident #4's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, heart disease, and Page 1 of 4 676238 676238 01/06/2024 Legend Oaks Healthcare and Rehabilitation - North 11020 Dessau Rd Austin, TX 78754

F 0880 type II diabetes. Level of Harm - Minimal harm or potential for actual harm Review of Resident #5's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including history of heart attack, type II diabetes, acute kidney failure, and muscle wasting and atrophy. Resident #5 is Resident #1's roommate. Residents Affected - Some Review of Resident #6's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), type II diabetes, hyperlipidemia (elevated lipid levels), and cognitive communication deficit. Resident #6 is Resident #2's roommate. Review of Resident #7's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (seizure disorder), unspecified dementia, muscle wasting and atrophy, and cognitive communication deficit. Resident #7 is Resident #3's roommate. Review of Resident #8's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including age-related physical debility, muscle wasting and atrophy, hypertensive heart disease, and dysphagia (difficulty with swallowing). Resident #8 is Resident #4's roommate. Observation on 01/05/24 at 12:11 PM revealed bins of PPE randomly placed throughout the 400 hall. CDC donning protocol was placed on the door of rooms 402 (Resident #1 and #5), 404 (Resident #2 and #6), 406 (Resident #3 and #7) and 414 (Resident #4 and #8 ). During an interview on 01/05/24 at 12:16 PM, LVN A stated rooms 402, 404, 406, and 414 had both a COVID-positive and COVID-negative resident. He stated if they moved the negative residents out, they could be exposing COVID to another resident who had not been exposed. He stated they also did not have many available open rooms to be able to move them to. During an observation and interview on 01/05/24 at 12:21 revealed CNA B in room [ROOM NUMBER]. She was moving furniture around by Resident #3's bed. She was wearing an N95 mask and no other PPE. Surveyor found the ADON and asked if staff should be wearing PPE in positive resident rooms and he said yes and went to address CNA B. During an observation and interview on 01/05/24 at 12:42 PM, revealed CNA C brining a lunch tray to Resident #3 in his room without any PPE other than an N95 mask. Surveyor asked CNA D if PPE was to be donned before entering a positive room and she stated, Yes! Oh no, did (CNA C) not put any on? During an interview on 01/05/24 at 12:44 PM, CNA C was asked if she was supposed to don PPE before she entered Resident #3's room. She shook her head yes. When asked why she had not worn a gown, gloves, or face shield, she immediately shrugged and walked off quickly. During an interview on 01/05/24 at 1:27 PM, the ADON stated PPE should be worn at all times when entering an isolation room, which included a gown, face shield, gloves, and N95 mask. He stated it was important to prevent the spread of infection. The ADON was asked if it was normal for the facility to keep a resident that tested negative and a resident that tested positive in the same room, he stated if there was space available then they would wanted to move the positive resident out of the 676238 Page 2 of 4 676238 01/06/2024 Legend Oaks Healthcare and Rehabilitation - North 11020 Dessau Rd Austin, TX 78754

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room, and the negative resident would need to be placed on warm precautions as they were presumed positive. He stated if there were no other rooms, they would leave them together and continue to try and keep them isolated. He stated they did not have a specific policy for COVID-19 but followed CDC guidance . During an interview on 01/05/24 at 1:39 PM, the ADM stated his expectations were that all staff members entering a COVID-positive room were to don a gown, face shield, gloves, and N95 mask . He stated the plan was to treat the confirmed positive and confirmed negative residents as if they were both positive because there was a fear that moving the residents around would only cause an increase in the spread of the infection. Review of an in-service, dated 12/31/23 and conducted by the DON, reflected staff were reeducated on infection control, COVID 19, and donning and doffing PPE. Attached to the in-service was CDC protocol on what to don before entering a COVID-positive room: face shield or goggles, N95 mask, gloves, and isolation gown. Review of the facility's Infection Prevention and Control Program, revised October of 2022, reflected the following: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Review of the facility's IPCP Standard and Transmission-Based Precautions Policy, revised October of 2022, reflected the following: 1. Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include: a. Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protection . 4. Droplet Precautions (TBP) are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking (e.g. influenza). a. Implement source control by placing a mask on the patient. b. Ensure appropriate patient placement in a single room if possible. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. 676238 Page 3 of 4 676238 01/06/2024 Legend Oaks Healthcare and Rehabilitation - North 11020 Dessau Rd Austin, TX 78754

F 0880 Review of the CDC website, updated 05/08/23, reflected the following: Level of Harm - Minimal harm or potential for actual harm If cohorting, only patients with the same respiratory pathogen should be housed in the same room. MDRO colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Residents Affected - Some . Personal Protective Equipment - HCP who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to Standard Precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. 676238 Page 4 of 4