Inspection·June 8, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of seven residents reviewed for accidents. The facility failed to ensure staff checked on Resident #1 from 05:15 am until 07:50 am during which time she laid on the floor next to the bed. This failure could place residents at risk for serious injury and distress that could result in a decreased psychosocial well-being. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted on [DATE] with a diagnosis of muscle wasting and atrophy, muscle weakness, lack of coordination, and dementia (memory loss). Record review of Resident #1's MDS assessment revealed a BIMS score of five indicating severe cognitive impairment. Further review revealed Resident #1 needed extensive assistance with two staff members for transferring and bed mobility. Record review of Resident #1's Care Plan dated 5/22/24, with a revision date of 6/05/24, revealed Resident #1 was at risk for falls due to medication use, cognition (mental status), and weakness. Record review of facility Incident/Accident form dated 6/08/24 revealed Resident #1 was found on the floor six times since admission on [DATE], 5/11/24, 5/14/24, 5/19/24, 6/02/24, and 6/05/24. Observation of Resident #1s room on 06/08/24 at 11:00 am, revealed Resident #1 bed in the lowest position, fall mat folded up and against the wall. Observation of video, dated 5/19/24 at 04:56 am, showed Resident #1 in the bed. Her bed was in lowest position. Then Resident #1 sat up and swung her legs over the side of the bed, both of her feet touched the ground. The Resident #1 laid back down. Fall mat was diagonal next to bed. Observation of video, dated 5/19/24 at 05:15 am, showed Resident #1 laying on the floor partially on fall mat with blankets. (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: 676067 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 676067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mira Vista Court 7021 Bryant Irvin Rd Fort Worth, TX 76132 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)