Health inspection·November 7, 2025

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, observation, 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 for one (Resident #1) of three residents reviewed for infection control. The facility failed to ensure Resident #1, who was on enhanced barrier precautions for ESBL, received tracheostomy care via sterile technique. This failure placed all residents at risk for the spread of infections and decreased quality of life. Findings included:Record review of Resident #1's face sheet, dated 10/30/2025, reflected the resident was a [AGE] year-old female, admitted [DATE], re-admitted [DATE] from an acute care hospital. Her DX included, malignant (cancerous) neoplasm (tumor) of upper lung lobe, hemiplegia (paralysis on one entire side of the body), cerebral infarction (stroke), dysphagia (difficulty swallowing), aphasia (difficulty speaking), HTN (high blood pressure), COPD (severe shortness of breath), and diabetic mellitus type 2 (non-insulin dependent) with neuropathy (nerve damage to hands and feet), and depression. Record review of Resident #1's admission MDS assessment, dated 10/30/2025, reflected she had a BIMS score of 8, which indicated moderate cognitive deficit due to chronic (long standing) disease processes. Resident #1 stated she was sad because she was unable to eat solid food due to her tracheostomy. Record review of Resident #1's care plan, dated 10/30/2025, reflected the resident was at high risk for further impaired cognition due to BIMS of 8. Resident #1 has had impaired communication due to being edentulous (no teeth) and difficulty speaking due to tracheostomy status. Resident #1 requires required assistance with all ADLs due to right side weakness from a stroke. Resident #1 was at risk for psychosocial well-being due to a diagnosis of depression. Resident #1 was on enhanced barrier precautions due to colonization (bacteria of the body not causing harm) of ESBL. Resident #1 received O2 and suctioning PRN and tracheostomy care with oral care every nursing shift. Interview and observation with Resident #1 on 11/07/2025 at 9:25 AM, revealed the resident was awake and alert to person and event. She exhibited difficulty speaking due to a dx of aphasia, tracheostomy status, and being edentulous. Observation of tracheostomy care on 11/07/2025 at 9:30 AM, revealed LVN A did not set up all needed supplies prior to starting the tracheostomy care. A previously opened bottle of clear liquid was used instead of sterile saline, per policy, to soak gauze sponges as well as used with sterile 14 French (size of the suction tube) suctioning tube to suction Resident #1 to clear secretions. LVN A broke sterile field (the nurse contaminated her sterile gloves) during tracheostomy care by reaching into Resident #1's bedside table during care to retrieve supplies with her sterile gloves on. LVN A did not stop the care procedure after contaminating the sterile gloves. During an interview on 11/07/2025 at 10:00 AM, LVN A indicated she realized she broke sterile field when she reached into Resident #1's bedside table to retrieve supplies she failed to set up before beginning the tracheostomy care. The bottle of clear liquid was identified as a previously used saline container which was no longer sterile. When Residents Affected - Few (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: 455606 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 455606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Care Center 3301 View St Fort Worth, TX 76103 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)