Health inspection·October 6, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 2 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's comprehensive person-centered care plan was not implemented and did not include measurable outcomes related to signs and symptoms of dehydration such as decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: Record review of Resident #1 admission record dated 10/04/24 reflected the resident was a [AGE] year-old male, who initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident#1 was diagnosed with: unspecified intellectual disability acquired absence of right leg below the knee, anemia chronic kidney disease, Type 2 diabetes mellitus with unspecified complications, protein calorie malnutrition and retention of urine unspecified. Record review of Resident#1's discharged MDS dated [DATE] reflected: the resident required substantial/maximal assistance, Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort, for toileting hygiene, shower/bathe self and lower body dressing. The MDS also reflected Resident #1 was always continent. Record review of Resident#1's Entry MDS dated [DATE] reflected Resident#1 had no BIMS assessement documented. Record review of Resident#1's care plan dated 08/21/24 reflected Problem: The resident has potential fluid deficit r/t decreased mobility, recent admit to facility. Intervention: Monitor/document/report to MD PRN s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, (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 7 Event ID: 675028 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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)