Health inspection·May 31, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to establish and 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 one resident (Resident #1) of three residents, reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure CNA A and CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 04/14/25, reflected he had had a BIMs score of 15 and was cognitively intact The MDS reflected that Resident #1 had the following diagnoses diabetes mellitus, heart failure, anemia, anxiety disorder, malnutrition, chronic obstructive pulmonary disease (COPD) (a progressive lung disease characterized by difficulty breathing due to persistent airflow obstruction). The resident was occasionally incontinent of bowel and bladder. The functional abilities of the resident were documented as dependent for toileting. Review of Resident #1's Comprehensive Care Plan, edited dated 02/026/25, reflected the resident had an activities of daily living selfcare deficit requires assistance setup/supervision, resident ability fluctuates related to shortness of breath. Facility interventions included: provide necessary equipment and adequate time for self-performance or participate with daily care. An observation on 05/31/25 at 11:21am revealed Resident #1 was in electric wheelchair. He was awake, alert, and oriented. CNA A and CNA B transferred resident to bed and prepared to perform incontinence care for the resident. Resident#1 had a bowel movement and brief was wet. CNA A performed peri-care and cleaned the front including his penis. CNA B performed peri-care and cleaned the buttocks. CNA A and CNA B did not change gloves or perform hand hygiene. CNA A and CNA B put a clean brief on the resident and covered him with the linens. CNA B put dirty diaper in plastic trach bag and removed gloves CNA A moved residents table arranged his personal belongings on his bedside table to include his water pitcher then removed gloves. An interview on 05/31/25 at 12:36pm revealed CNA B knew that she was supposed to change gloves and perform hand hygiene but did not want to because she was moving fast and the surveyor was watching her she got nervous. (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: 676132 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 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 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)