Health inspection·April 20, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Residents #1) of two residents reviewed for dignity. The facility failed to promote Resident #1's dignity by not covering his catheter urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Review of Resident #1's MDS quarterly assessment, dated 03/17/23, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included heart failure, hypertension (high blood pressure), diabetes mellitus, and renal failure. The assessment reflected the resident had moderate cognitive impairment, with a BIMS score of 09. Review of Resident #1's care plan, dated 03/07/23, reflected: Resident #1 has an indwelling foley catheter due to urinary retention in hospital. The resident will show no s/sx of Urinary infection through review date. The resident will be/remain free from catheter-related trauma through review date. Observation and interview on 04/20/23 at 11:03 AM revealed Resident #1 in his wheelchair entering the dining area from outside. Resident #1 was propelling himself through the dining area. The resident's urinary collection bag was observed to be suspended from underneath the resident's wheelchair. The resident's urinary collection bag was not in a privacy bag, and urine was visible inside the collection bag. Resident #1 revealed he took a shower this morning with the assistance of CNA B. He stated he always had a privacy bag, and he was given a new privacy bag yesterday but did not know what happened to it. Interview on 04/20/23 at 11:11 AM with CNA B revealed he assisted Resident #1 with a shower this morning and got him ready. CNA B stated Resident #1's urinary collection bag did not have a cover. He stated he had asked LVN A for a new privacy cover, but he thought LVN A might have forgotten. He stated the collection bag should have been covered to ensure the resident's privacy and respect his dignity. (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: 675977 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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)