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 (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 2 Event ID: 676223 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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)