Health inspection·July 2, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers that were avoidable for 1 of 14 residents (Resident #28) reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #28's physician ordered pressure relief boots were placed on Resident #28's feet while he was laying in his bed. This failure could place residents at risk of having skin breakdown . Findings included: Record review of Resident #28's face sheet dated 07/02/2024 revealed a [AGE] year-old male admitted on [DATE] with an original admission date of 08/29/2022, with diagnosis of Spastic Quadriplegic Cerebral Palsy(, disorder of bone density and structure, protein-malnutrition and muscle weakness. Record review of Resident #28's Quarterly MDS assessment dated [DATE], revealed: Section C-Cognitive Patterns, Resident #28 had a BIMS score of 0 meaning Resident #28 was given the assessment because he was rarely/never understood; Section GG-Functional Abilities and Goals, Resident #28 was dependent on staff for all ADL's; Section M- Skin Conditions, Resident #28's skin intact , no pressure ulcers. Record review of Resident #28's physician orders revealed Start date of 12/30/2022 Keep bed in low position, pressure relief scoop mattress, pressure relief cushion to w/c [wheel chair], pressure relief boots to feet for prevention. Every day and night shift During an observation on 06/30/2024 at 9:10 AM , Resident #28 laying in his bed. Resident #28's bed was in lowest position. Pressure relief boots were laying on top of the covers and were not on Resident #28's feet. During interview on 07/02/2024 at 12:24 PM the ADMN stated he would refer any clinical questions to his DON and the staff should have followed the policies of the facility. During an observation and interview on 07/02/2024 at 12:55 PM, the DON stated Resident #28 should have been wearing pressure relief boots on both his feet to prevent pressure ulcers. The DON stated if the order stated every day and night shift, then the boots should be on when Resident #28 was laying in bed. The DON stated Resident #28 did not have any skin issues, the order for pressure relief boots was to prevent pressure ulcers. The DON lifted the sheet up to reveal that Resident #28 was not (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 4 Event ID: 675377 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 07/02/2024 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)