Cityview Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0584
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure residents were provided with a clean and comfortable environment by providing clean bed linens that are in good condition for 1 of 7 resident (Resident #1) reviewed for safe environment.The facility failed to ensure Resident #1' s bedding was changed when it was saturated in urine. This failure could place the resident at risk of skin breakdown and decreased feelings of self-worth. Findings included:Record review of Resident #1's admission MDS assessment, dated 12/05/25, indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE REDACTED]. Diagnoses included cancer of the intestines that had spread throughout the body, mass on the left kidney requiring the placement of a drainage tube, and acute kidney failure. His BIMS score was 14, indicating his cognition was intact. His Functional Ability assessment indicated he was dependent on staff for his toileting hygiene. His Bowel and Bladder assessment indicated he was occasionally incontinent of urine. Record review of Resident #1's care plan, dated 12/17/25, reflected Resident #1 had an ADL self-care deficit related to functional decline, he was incontinent of bowel and bladder, and was on a diuretic (medication use to remove excessive fluid from the body). Interview and observation on 01/29/26 at 11:09 AM revealed Resident #1 lying in bed the draw sheet under him was saturated with dried urine, as indicated by the brown color. The resident stated his bedding had not been changed since the previous evening. He stated no one had checked on him that morning. He stated he did not realize the bedding was wet, and was not sure when it happened, so he had not notified staff. Interview on 01/29/26 at 11:14 AM CNA-A she stated she had not checked on Resident #1 yet; she had been busy with other residents. She was unaware
the resident was incontinent of urine. She did not feel overworked as there were other CNAs on the hall.
Interview on 01/29/26 at 11:19 AM the ADON stated there was no reason Resident #1 should have been left on dirty linen. He stated the night shift should have noticed it and changed it, or CNA-A should have noted it earlier in her shift when she made rounds on all her residents. He stated his expectation was for the CNAs and nurses to round on all their residents at the beginning of their shift to assess for needs. He stated the risk of a resident lying in urine-soaked linen could result in skin breakdown or irritation.
Observation on 01/29/26 at 11:25 AM of Resident #1's peri area and buttocks revealed no skin breakdown or excoriation. There was some redness present from lying on his back. Interviews on 01/29/26 from 11:35 AM to 12:00 PM with residents of the hall revealed no complaints about linen not being changed when dirty.
Staff checked on them regularly, and needs were being met.Review of the facility's policy Activities of Daily Living, dated 5/26/23, did not address changing linen specifically. It did address: Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 3. Toileting.
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
Event ID:
Cityview Nursing and Rehabilitation Center in Fort Worth, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Fort Worth, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Cityview Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.