Inspection·March 12, 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 observation, interview, and record review the facility failed to 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 1 of 4 residents (Resident #1) observed for infection control. Residents Affected - Few LVN A failed to properly dispose of soiled dressings and guaze when she provided with Resident #1 with wound care. This failure could lead to cross contamination and infection. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who admitted to the facility on [DATE] and readmitted on [DATE]. The resident had severe cognitive impairment with a BIMS score of 0. The MDS reflected Resident #1 had skin conditions, and he had diagnoses of an open lesion and pressure ulcer/injury. Record review of Resident #1's care plan dated 02/26/25 reflected the following: Problem: [Resident #1] has a lymphademic wound [a condition where excess lymph fluid accumulates in the tissues] to left posterior lateral calf. Goal: [Resident #1] lymphademic wound to left posterior lateral calf will heal without complications. Implement: Apply dressings per MD order. Problem: [Resident #1] has a lymphademic wound to right posterior lateral calf. Goal: [Resident #1] will not acquire any new open areas. Approach: Avoid shearing resident's skin during positioning, transferring, and turning. Problem: [Resident #1] has a Stage 4 pressure [involves full-thickness skin and tissue loss, exposing underlying structures like muscle, tendon, or bone] area to sacrum [the triangular bone that connects the lumbar spine and the pelvis] Goal: [Resident #1] ulcer will heal without complications. Approach: Treatment per MD order. Observation on 03/12/25 at 10:07 AM revealed LVN A preparing to provide Resident #1 wound care. LVN A washed her her hands, put on gloves, disinfected the table, and left it to dry. She then explained the procedure to Resident #1. She removed her gloves and washed her hands. She then put all the supplies together. LVN A next washed her hands, put on PPE, and put the feeding pump on hold. LVN A then removed the old dressing on the resident's left lower leg (calf) that was soiled with drainage, (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 03/12/2025 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)