Inspection·May 24, 2023

F 0609 Review of Resident #27's Care Plan, started 3/27/23 revealed: Level of Harm - Minimal harm or potential for actual harm Focus: Resistive with care due to cognitive loss and diagnosis of Alzheimer's and dementia Goal: Resident #27 will be compliant with all necessary care Residents Affected - Few Interventions: allow resident to express preferences and follow these when possible and meet resident's needs as is possible and explain what it is being done to meet needs. Review of Resident #27's Care plan, started 3/30/23, revealed: Focus: Resident #27 sometimes has behaviors which include cursing, hitting during care, kicking, screaming, and shouting. Goal: Resident #27 will calm down with staff intervention daily Interventions: attempt interventions before resident's behaviors begin. Review of Resident #27's Order Summary Report, dated 5/23/23, revealed he was not on any anti-coagulant, anti-platelet, or Non-steroid Anti-inflammatory Drug. Review of Resident #27's Nurse's Notes 4/22/23 - 5/23/23 revealed no notes about bruises to Resident #27's arm. Review of Resident #27's only incident/ accident report revealed an incident/ accident report, dated 5/20/23, completed by LVN D that documented yellow, healing bruises. Observation on and interview on 05/22/23 at 12:26 PM revealed Resident #27 in his room up in his wheelchair. Resident #27 was observed to have a bruise near his arm. Family member pulled up the arm to his shirt and showed surveyor the bruising on the bicep of his left arm with a skin tear in the middle. Resident #27's family member told the facility she did not know what happened. The bruise on his arm was a red crescent shaped bruise to the outside of the arm. On the inner arm was a dark purple oval shaped bruise. Observation and interview 05/23/23 at 11:41AM showed Resident #27's bruises measured approximated 2.5 - 3 inches long for the crescent bruise. The inner arm bruise was approximately an inch and matched the outline of a thumb. Interview on 05/23/23 at 3:04 PM CNA C stated Resident #27 was fairly new and excessive assistance on everything. She said he got fairly aggressive at times and clocked her about a week ago. She said she was not sure how long Resident #27 had the bruise on his arm. CNA C said she became aware of the bruise when she came back from her days off last week and no one told her about them. She stated when she found the bruising on Resident #27's arm she reported it to her nurse. CNA C said she just remembered a circular bruise on his arms. CNA C stated a circular bruise might be from someone grabbing him or being pulled up CNA C stated when she found a bruise on a resident, she would bring it to her charge nurse or ADON. Interview and observation on 05/23/23 at 3:18 PM LVN A stated Resident #27 had Alzheimer's disease and had lot of behaviors. LVN A explained Resident #27 would punch and fight and kick when he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 2 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few changed. LVN A said she did not know anything about a bruise on Resident #27 and stated she needed to measure it. Resident #27 was observed in bed asleep. LVN A was able to measure the bruise on Resident #27's arm; due to the way Resident #27 was laying, she was able to measure the red crescent bruise on the bicep at 1.5 cm x 1.5 cm and the skin tear was 1.5 cm long. LVN A stated she would complete an incident/accident report on the bruise. LVN A stated no one told her of any bruising in shift to shift report. LVN moved Resident #27's arm to examine the inner arm and stated the purple bruise looked like a thumb print but was unable to measure it. Interview on 05/23/23 at 3:34 PM the ADON stated she was not sure how Resident #27 got the red or purple bruises on his arm. She stated she tried to look at Resident #27's arms but Resident #27 would not let her look at it. Interview on 05/24/23 at 9:15 AM the ADON stated she went into Resident #27's room when he got undressed. The ADON stated she though the incident/accident report completed on 5/20/23 was about different bruise(ing). She confirmed she saw the bruise when he got undressed. The ADON stated she did see the inner arm bruise and stated it was purple, in-tact and non-blanchable. The ADON said she thought he hit the half-rail on his bed, she continued she thought it would form an oval bruise (the half rail was long, straight, smooth plastic bar structure for resident to grab during ADL care). When it was pointed out the half rail was long and thin, the ADON said he might have bumped it on his wheelchair (wheelchair arms are padded, long and thin). The ADON said to rule out staff mistreatment, they talked to the staff and everything. The ADON stated Resident #27 was unable to explain what happened, but if someone did something to him, he did not like he'd get you. The ADON stated if the bruise was from someone holding too tightly there would be a bruise from the fingers as well. The ADON said the 5/20/23 skin assessment did not document any new skin issues. The ADON said to investigate the bruises she called Resident's #27's Responsible Party and they did not think anything happened. Interview on 05/24/23 at 9:41 AM the Administrator stated the only bruising he was aware of was old bruising discovered 5/20/23 that was yellow. He was not aware of the red or purple bruise. He said causes of bruising could be a transfer not done right or a resident-to-resident altercation. The Administrator stated he did not look at Resident #27's arm. The Administrator admitted he did not do anything to rule out abuse or neglect. He admitted he did receive training for abuse and neglect, and it covered mandatory reporting and suspicious injuries. The Administrator stated suspicious injuries could be inner soft skin and the face. Interview on 05/24/23 at 11:00 AM LVN D said she worked 5/20/23 and did not find red or purple bruisng. LVN D said she did not know how the aides provided ADL care and not notice the red or purple bruising, but neither knew about it. LVN D said she worked on Friday 5/19/23 and no one said anything about bruising at that time. LVN D said Resident #27 was always agitated during care and needed two-people for assistance. LVN D said there was nothing abnormal about 5/19/23 or 5/20/23. Review of the facility's policy and procedure on Abuse Prevention Program, dated 1/2022, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: Develop and implement policies and procedures to aide our facility in preventing abuse, neglect, or mistreatment of our residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 3 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

F 0609 Resident staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior. Level of Harm - Minimal harm or potential for actual harm Identify and assess all possible incidents of abuse Residents Affected - Few Investigate and report any allegation s of abuse within timeframes as required by federal requirements. Review of the facility's policy and Procedure on Abuse and Neglect - Clinical Procedure, dated 1/2022 revealed: Assessment and Recognition: The nurse will assess the individual and document related findings. Assessment data will include: a. injury assessment (Bleeding, bruising, deformity, swelling etc.) b. pain assessment c. current behavior d. Patient's age and sex e. All current medications, especiall7y anti-coagulants, Non-Steroidal, Anti-Inflammatory Drugs, salicylate. f. Other platelet inhibitors g. Vital sighs. h. Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior) i. History of any tendency towards bruising j. All active diagnoses. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents/ patients with unmanageable problematic behavior. Cause identification: the staff with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 4 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to label medications in accordance with currently accepted professional principles, and include the the expiration date , and to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one of one medication room and one (cart #1) of one treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to label multi-use vials of tuberculin and influenza formula with the open date The facility failed to ensure treatment cart #1 was locked when unattended on 05/22/2023 and 05/24/2023. These failures could place residents at risk of being administered expired medications and having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and record review on 05/23/23 at 3:02 PM the medication room was observed with LVN A present. Inside a small refrigerator there were two opened 1ml vials of tuberculin formula that did not have an open date on them. The tuberculin box indicated Discard opened product after 30 days. There also was a one opened 5ml vial influenza vaccine formula vial that did not have an open date on it. The influenza formula manufacture pamphlet dated March 2022 indicated in part: Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. During an interview on 05/23/23 at 3:12 PM LVN A said she did not know if someone was designated to check the medication room for expired medications. LVN A said she would definitely start checking for expired medications in the medication room from now on. During an interview on 05/24/23 at 10:30 AM the ADON said normally the nurses were supposed to monitor the medication room for expired medications and such. The ADON said she checked the medication room once a week but she must have missed those vials. The ADON said if they used an expired vial medication it could lead to inaccurate readings or not get the desired effect. During an interview on 05/24/23 at 12:02 PM the Administrator said it was the nurses duty to monitor the medication room for expired medications and discard them if not dated (out of date). Record review of the facility's policy titled Medication labeling and storage dated 02/2023 indicated in part: The medication label includes at a minimum - expiration date when applicable. Multi-dose vials that have been opened or accessed (e.g. needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. During an observation and interview on 05/22/2023 from 3:05 PM to 3:09 PM, treatment cart #1 was observed unlocked and unattended. There were no facility staff observed near the treatment cart or seen, all drawers of the medication cart were unlocked, and all medications, supplies, and additional items were easily accessible with no staff in eyesight of the treatment cart. Surveyor waited by cart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 5 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

F 0761 for 4 minutes before a LVN D walked by and took the cart. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 05/24/23 08:30 AM to 08:50AM, treatment cart #1 was observed unlocked and unattended. There were no facility staff observed near the treatment cart or seen, all drawers of the medication cart were unlocked, and all medications, supplies, and additional items were easily accessible with no staff in eyesight of the treatment cart. Surveyor waited by cart for 20 minutes before a LVN D arrived. LVN D was questioned about who was responsible for locking the cart. LVN D stated that she and the other nurse shared the treatment cart. Surveyor asked why the cart was unlocked, LVN D shrugged her shoulders and stated that she would lock the cart when she finished what she was doing. Residents Affected - Few In an interview on 05/24/23 at 1:10 PM, the ADON stated the carts should never be left unlocked and unattended. ADON stated that her expectations were that staff should be locking carts. The ADON stated that she recently put out an in-service on unlocked carts because it had been a problem. ADON stated that she is constantly telling the nurses to lock the carts. ADON stated that she would re-educate the nurses on importance of locking carts for safety of residents. Review of the facility's policy, titled Security of Medication Cart, revised April 2007, reflected (in part): Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the residence room during the medication pass. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The card must be locked before the nurse enters the residence room. 4. Medication carts must be securely locked at all times went out of the nurses view. 5. When the medication cart is not being used, it must be locked and parked at the nurses station or inside the medication room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 6 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

F 0761 Review of facilities mandatory in-service, dated 04/01/2023, titled Locking Medication Carts Level of Harm - Minimal harm or potential for actual harm Topic discussed: When not standing directly in front of medication heart, the cart must be locked, and the computer should not contain patient information. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 7 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

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 control program designed to prevent the development and transmission of disease and infection. Residents Affected - Some PT B double gloved during incontinent and wound care for Resident #23 and did not sanitize or wash her hands in between glove changes. PT B failed to perform hand hygiene prior to leaving room after performing wound care and incontinence care. CNA C failed to perform hand hygiene or glove changes during incontinent care of Resident #25. CNA C touched residents clothing and linens with soiled gloves after conducting incontinence care. These failures could place resident's risk for cross contamination and the spread of infection. Findings included: Record review of Resident #23's admission record dated 05/23/23 indicated he was admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral region, muscle wasting and atrophy. He was [AGE] years of age. Record review of Resident #23's MDS dated [DATE] indicated in part: Bladder and Bowel: Bowel Continence = 3. Always incontinent (no episodes of continent bowel movements). Record review of Resident #23's physician orders active as of 05/23/2023 indicated in part: Cleanse stage 4 to sacrum with antimicrobial skin and wound gel and pat dry. Apply 2x2 to cover wound bed. Apply thin layer of sure-prep (A skin protectant wipe that forms a waterproof barrier on skin) )around wound and cover with dressing. LT (left) heel= After CPI (Closed Pulse Irrigation) irrigation by therapy. pat dry, apply hydrogel impregnated gauze on wound bed &cover with dry gauze and foam dressing Monday to Friday. Record review of Resident #23's care plan dated 05/17/2023 indicated in part: Focus: Potential for complications related to incontinence of bowel. Goal: Resident will be free from complications r/t incontinence as evidence by intact skin, no rash or redness to peri care, no signs or symptoms of infection daily. Interventions: Clean peri area thoroughly after each episode of incontinence, assess, assess skin after each episode of incontinence-notify nurse with any problems. Focus: Infection actual or at risk for related to: Stage 3 decubitus ulcer to sacrum. Goal: Infection will resolve without complication . Interventions: Follow standard precautions refer to Living Center Infection Control Manual. Record review of Resident #25's admission record indicated she was admitted to the facility on [DATE]. Diagnoses included epilepsy, full incontinence of urine and bowel, intellectual disabilities. She was [AGE] years of age. Record review of Resident #25's MDS dated [DATE] indicated in part: Bladder and Bowel: Bowel Continence = 3. Always incontinent (no episodes of continent bowel movements). Record review of Resident #25's care plan dated 05/17/2023 03/13/23 indicated in part: Focus: Resident has bowel/bladder incontinence and is at risk for skin breakdown and UTI's. Goal: Residents risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 8 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for septicemia will be minimalized /prevented via prompt recognition and treatment of symptoms of UTI through the review date. Resident will remain free from skin breakdown due to incontinence and brief use. Intervention: Clean peri area with each incontinence episode, handwashing before and after delivery of care. During an observation on 05/22/23 at 02:42 PM PT B performed wound care to Resident #23's coccyx area. PT B sanitized her hands and put on 1 pair of gloves on both hands. PT B undid the brief and noted the resident had a bowel movement, so she took some wipes and wiped bowel movement. While still wearing the same original gloves that she used to wipe the bowel movement, PT B took a clean pair of gloves and put them over the soiled pair of gloves she was already wearing. PT B then placed a clean cloth pad under the resident and removed the dressing from the wound on Resident #23's coccyx area. PT B then removed the first pair of gloves and placed another clean pair of gloves over the ones that she used to clean the bowel movement. PT B then took some sure-prep pads and wiped around the wound area and placed a plastic dressing over the entire coccyx are while still wearing the same double gloves. The resident had more bowel movement, so PT B wiped the bowel movement with some wipes then removed those gloves and put on another pair over the ones she already had on. PT B then took some 4x4 gauze and cleaned the wound then she removed the pair of gloves and put on a new pair over the ones she had on from the beginning. While wearing the same pair of gloves PT B took a clean cloth pad and placed it under Resident #23 then took a clean brief and fastened it to him. While wearing the same pair of gloves PT B took a clean pair of shorts and assisted the resident with putting them on. PT B then removed both gloves from her left hand but only one glove from the right hand, she then placed a new glove over the old glove on right hand and placed 2 gloves on her left hand without sanitizing or washing her hands. PT B then took a plastic dressing and placed it on Resident #23's left foot. PT B's cellphone rung so with the gloved hand took the cellphone from her shirt pocket and pressed a button to silence it, placed the phone back in her pocket and proceeded with the wound care. While wearing the same gloves PT B took the CPI machine and debrided the ankle with the sodium chloride solution. PT B then removed the plastic dressing, removed the first pair of gloves while leaving the old pair still on and then took a clean pair of gloves and donned them over the old pair. After PT B was done with the care, she placed the used items in a bag and removed her gloves and placed them in the bag and left the room without sanitizing or washing her hands. During an observation and interview on 05/23/23 at 04:00 PM, CNA C washed hands, donned gloves, pulled curtain, and used the remote to adjust bed to lay resident flat. CNA C removed resident #25's pants, and folded residents soiled brief in on itself. CNA C wiped resident's perineal area x5 with wet wipes, then rolled resident to her left side and wiped residents bottom x3 with wet wipes. CNA C removed soiled brief, and dried residents bottom with a dry towel, then placed new brief under resident and then rolled resident and dried resident front perineal area with a clean dry towel. CNA C secured residents brief. CNA C covered resident with her blankets and adjusted her pillows. CNA C lowered bed to lowest position using the remote. CNA C doffed her gloves and washed her hands. CNA C failed to perform hand hygiene, use hand sanitizer or change gloves during incontinent care of Resident #25. During an interview on 05/24/23 at 10:42 AM the ADON said staff was expected to remove their gloves if they became contaminated with bowel movement. The ADON said staff were then expected to wash their hands and the put- on clean gloves to continue the care. The ADON said staff were supposed to only put one pair of gloves at a time and not double glove. The ADON said staff were not supposed to double glove because the first pair of gloves could become damage and contaminate the other pair. The ADON said the PT staff should have removed both gloves and washed their hands before putting on another pair of gloves. The ADON said PT B not changing her gloves and washing her hands could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 9 of 10 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 675377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bangs Nursing and Rehabilitation 1105 Fitzgerald Bangs, TX 76823 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lead to cross contamination. The ADON said she did training, on a monthly basis, regarding hand washing and glove use and all staff was present including the therapy staff. The ADON said she would do more training on the use of gloves and hand washing. During an interview on 05/24/23 at 11:56 AM PT B said she should have probably changed her gloves once they became contaminated and washed or sanitized her hands. PT B acknowledged that using double gloves was not appropriate and would not do that anymore. PT B said she attended the in-services they had at the facility regarding hand washing and glove use and she should have been more careful to prevent cross contamination. During an interview on 05/24/23 at 12:04 PM the Administrator was made aware of the observation of PT B using double gloves and not washing or sanitizing their hands in between glove changes. The Administrator acknowledged it was a concern and there would be more training regarding handwashing and glove changing. Record review of the facility's policy titled Handwashing/Hand Hygiene and dated 08/2019 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: When hands are visibly soiled. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single use disposable gloves should be used before aseptic procedures; when anticipating contact with blood or bodily fluids and when in contact with a resident or the equipment or environment of a resident who is on contact precautions. Record review of the facility's policy titled Personal protective equipment-using gloves and dated 09/2010 indicated in part: When gloves are indicated use disposable single use gloves. Wash hands after removing gloves (Note: Gloves do not replace handwashing). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675377 If continuation sheet Page 10 of 10