F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide treatment and services to prevent
complications of enteral feeding for one of five residents (Residents #1) reviewed for feeding tubes.
The facility failed to provide treatment for Resident #1 dressing around g-tube site was labeled 08/20/23.
The g-tube site was observed on 08/23/24.
These failures could place residents at risk of infection.
Findings included:
Record review of Resident #1's face sheet dated 08/23/24 reflected the resident was a [AGE] year-old
female with and admission date 06/02/21 and a readmission date of 08/07/24. Resident #1 diagnoses
included: benign neoplasm of bones of skull and face (benign growths of bone that typically occur in the
skull or jawbone), unspecified dementia, dehydration, and dysphagia-oral phase (difficult swallowing).
Record review of Resident #1's Annual MDS Assessment, dated 08/13/24, reflected Resident and had
BIMS score of 99 because resident was unable to complete interview. Section K swallowing/nutritional
status reflected A) proportion of total calories the resident received through parenteral, or tube feeding is
51% or more. B) Average fluid intake per day tube feeding was 501 CC/day or more.
Record review of Resident #1's care plan dated 08/14/24 reflected: Problems: [Resident #1] had a g-tube in
place. Goals: [Resident #1] had a stable weight as evidenced by no significant weight loss of 5% or more in
30 days .Approach: Administer feeding via g-tube as ordered.
Record review of Resident #1's Physician Orders report dated 08/23/24 reflected: Enteral Feeding: Tube
site care. Once a day (10:00 PM-6:00 AM) every day and ordered on 07/17/24.
Observation on 08/23/24 at 12:15 PM revealed Resident #1 g-tube site dressing had a date of 08/20/24.
Interview on 08/23/24 at 1:47 PM with LVN A revealed overnight staff handled changing residents g-tube
site dressing. LVN A revealed residents were at risk of developing an infection.
Interview on 08/23/24 at 1:52 PM with LVN B revealed the overnight shift handled changing residents
g-tube site dressing every day. LVN B stated residents were at risk for skin break down and
(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
08/28/2024
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)
F 0693
infection.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 08/23/24 at 2:10 PM with the DON revealed the treatment nurse handled changing g-tube site
dressing Monday-Friday. She stated the overnight nurse handled changing the g-tube site dressing
Saturday-Sunday. She revealed the electronic health monitoring system showed when task was needed to
be completed in yellow, due in green and red when late. She revealed the tasked disappeared out of the
system until the next schedule time. The DON stated she expected staff to check the g-tube site dressing
when medication was administered. She stated residents were at risk of skin break down and infection such
as yeast.
Residents Affected - Few
Interview on 08/23/24 at 2:32 PM with the Treatment Nurse revealed she just started last week and Monday
the 08/19/24 was her first day doing wound care by herself. The Treatment Nurse stated she believed a
different shift took care of the g-tube site dressing. The Treatment Nurse stated not changing the g-tube site
dressing could have caused skin break down.
Interview via telephone on 08/27/24 at 11:30 AM with Nurse Practitioner C revealed the g-tube site
dressing should be changed daily. The Nurse Practitioner stated residents have a likely hood for infection,
drainage when g-tube site dressings were not changed.
The DON was asked to provide a copy of the electronic monitoring record for Resident#1 related to g-tube
site care from 08/20/24 to 08/23/24; however, this was not provided to the investigator prior to exit.
Record review of the facility's Gastrostomy Tubes policy, dated May 2023, reflected: .2. The patient/resident
that is fed enteral methods receives the appropriate treatment and services to restore oral eating skills and
prevent complications of enteral feeding .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676067
If continuation sheet
Page 2 of 2
