Inspection·October 12, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 resident (Resident #12) out of 6 residents reviewed for care plans in that: Resident #12 did not have a baseline care plan created within 48 hours when she was first admitted to the facility. A past noncompliance was determined to have existed from 09/27/23 through 09/30/23.The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice affects residents who are new admissions and could result in decreased quality of care. The findings included: Record review of Resident #12's electronic face sheet dated 10/11/2023, revealed she was initially admitted to the facility on [DATE]. Resident #12 was a [AGE] year-old female. Her diagnoses include Cervical Disc Disorder with Myelopathy, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes with diabetic neuropathy, and history of falling. Resident #12 is allergic to: Iodine I 131 Tositumomab, Naproxen, Darvon, Citrus products, and Latex. Record Review of Resident #12's MDS, of her BIMS Interview/Observation, dated 9/27/2023, indicated a score of 15 out of 15 showing she was cognitively intact. Further review showed she was a fall risk and needed help with assisted daily living. Observation and interview on 10/10/23, at 1:44 PM - revealed Resident #12 was sleeping in bed but responded to questions. Interview on 10/10/2023, at 1:45 PM with Resident #12, revealed she came here from a hospital because she had a fall and was injured. She needed help with ADLs. She usually was in pain and was on pain medication. Review of Resident #12's Care Plan, dated 9/30/2023, revealed the resident had an ADL deficit, was (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 6 Event ID: 675650 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd 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)