Health inspection·December 11, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two (Resident #57 and Resident #68) of five residents, reviewed for incontinence. 1. The facility failed to ensure Resident #57 and Resident #68 did not have their Foley Catheter bags lying on the ground. This failure placed residents at risk for healthcare associated cross contamination and urinary tract infections.Findings included: 1. Review of Resident #57's Quarterly MDS Assessment, dated 10/28/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were severely impaired. His BIMS score was 06. The resident had a Foley Catheter (catheter inserted into the bladder to drain urine). His diagnoses included obstructive uropathy (blockage in the urinary tract). Review of Resident #57's Care Plans reflected:1. Revised 12/10/25 - Resident #57 had increased risk for infection due to collection bag placement and residents need for independence re: using bed controls and collection bag placement.Facility interventions - Date Initiated: 12/09/25 (this intervention was added after the State Surveyor observed the resident's catheter bag on the floor.)Position catheter bag and tubing below the level of the bladder and in a privacy bag. An observation on 12/09/25 at 11:18 AM of Resident #57 revealed he was lying in bed. He said he did not want to be interviewed. His Foley Catheter bag was lying on the floor. He said he did not know why it was on the floor. An interview on 12/09/25 at 2:25 pm with CNA B revealed she saw Resident #57's Foley Catheter bag on the floor the morning of 12/09/25. She said she did not know why it was on the floor. She said when she saw it (unknown time), she picked it up and put it back on the bed frame. CNA B said the resident had a remote control on the bed and it made it easy for the Foley Catheter bag to fall to the floor. CNA B said the resident was at risk for infection if the Foley Catheter bag was on the floor. 2. Review of Resident #68's Quarterly MDS Assessment, dated 11/25/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were intact. His BIMS score was 15. The resident had a Suprapubic Catheter (catheter inserted directly into the bladder to drain urine). His diagnoses included neurogenic bladder (nerve damage that disrupts bladder control). Review of Resident #68's Care Plans reflected:Revised 12/10/25 - Resident #68 had a suprapubic catheter and was at risk for complications.Facility interventions Date Initiated: 12/09/25 (this intervention was added after the State Surveyor observed the resident's catheter bag on the floor.)Educate resident on proper placement of bag as he tends to grab and move it. An observation and interview on 12/09/25 at 10:45 AM with Resident #68 revealed the resident was sitting upright in bed. He was awake, alert, and oriented. The resident's Foley Catheter bag was lying on the floor. The resident said he did not know why it was on the floor. The resident grabbed the Foley Catheter tubing and pulled the bag to himself and off the floor. The resident then (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 3 Event ID: 455763 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 455763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Bend Rehabilitation and Healthcare Center 301 Huguley Blvd Burleson, TX 76028 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)