Health inspection·March 22, 2024

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 and interview, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one of five residents (Resident #1) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA A failed to performed hand hygiene before providing ADL care (repositioning) for Resident #1. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #1's admission Record reflected an 81 -year-old female was admitted on [DATE]. The resident had a primary diagnosis of METABOLIC ENCEPHALOPATHY (a problem with the brain, caused by a chemical imbalance in the blood). Review of Resident #1's Care Plan , dated 02/20/2024 reflected Care Plan Type: ADLs/Mobility: 1-2 STAFF TRANSFER INTO THE GERI-CHAIR, Assist with mobility and ADLs as needed. INCONTINENT CARE PROVIDED BY STAFF, STAFF SPOON FEEDS RESIDENT, STAFF TURNS AND REPOSITIONS RESIDENT IN BED. Observation on 03/19/2024 at 3:14 PM with CNA A revealed Resident #1's room did not have a box of gloves or hand sanitizer. CNA A entered Resident #1's room wearing gloves. CNA A touched both the outside and inside door knob, and touched the call light panel button prior to requesting assistance from Resident #1's family member to grab the sheet to reposition the Resident. CNA A did not perform hand hygiene, CNA A grabbed the sheet and moved the resident up on the bed then with gloved hands touched the resident's bare skin on her leg and shoulder and repositioned the resident onto her back. Observation and Interview on 03/19/2024 at 3:17 PM with CNA A revealed CNA A stated she put on gloves before entering the resident's room for infection control when entering the room. She stated that she was aware that Resident #1's room did not have a box of gloves, therefore, prior to entering the room she put additional gloves in her pants pocket from the box of gloves on her cart in the hallway. She repeated that the gloves in her pant pocket were clean because she got them out of the box and then put them in her pocket. CNA A stated that she would then provide incontinent care for Resident #1. CNA A then removed gloves, washed her hands at the sink in resident's room, retrieved gloves from her side pocket, and placed the gloves on her hands then stated she would provide incontinent care for Resident #1. (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: 455891 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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)