Health inspection·April 1, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent the neglect of residents for one (Resident #1) of five residents reviewed for injury of origin. Residents Affected - Few The Administrator and DON failed to implement the facility's written policies and procedures on 03/28/24 that prohibit and prevent neglect of residents. Resident #1 was found on the floor in her room by a family member on 03/28/24 and subsequently had a serious injury, bleeding on the brain. The Administrator and DON failed to thoroughly investigate the injury of origin of Resident #1. The Administrator failed to report the injury of origin for Resident #1 to the State agency within the given time frame. These failures could place residents at risk for not having allegations of injury of origin investigated. Findings included: Record Review of face sheet dated 03/30/24 revealed Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: spinal stenosis-cervical region (narrowing of the spinal canal in the neck), muscle weakness, dysphagia-oropharyngeal phase (swallowing disorder sucking, chewing, and moving food or liquid into the throat), cognitive communication deficit, encephalopathy (a disease that affects brain structure or function that causes altered mental status and confusion), and Bell's palsy (facial palsy). Record review of Resident #1 MDS dated [DATE] revealed Resident #1 had no BIMS score noted. Record review of Resident's #1's care plan dated 03/28/24 reflected: Resident has limited physical mobility related to weakness. Goal: Resident will remain free of complications through next review date. Interventions: .Staff to assist with all transfers and ambulation as needed .Focus: Resident is at risk for falls related to weakness Goal: Resident will not sustain serious injury requiring hospitalization through the review date. Interventions: assist with ADLs .Call light within reach and complete fall risk assessment . Record review of the NRSG: Fall Risk Evaluation completed by LVN L dated 03/29/24, revealed the resident scored a 16. Scores between 16-20 represented starting the fall protocol, with the resident being at high likelihood of a fall occurring. Record review of Resident #1's progress notes dated 03/28/24 reflected Resident #1 had an unwitnessed fall, resident found on the floor by family, upon entering the room resident was laying on her Page 1 of 5 675650 675650 04/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left side, bilateral [both] lower extremities extended, Bump noted on the left forehead, no loss of consciousness, v/s obtained, 151/90, HR 87, SPO2 100, TEMP 98.0, resident able to move all extremities without any difficulties, neuro checks initiated per facility protocol and are WNL. resident assisted back to the bed with three person assist, nurse sent resident to the ER for further evaluation, Resident last checked 10 min prior to fall notification, resident behaviors, refused medication, refused dinner , alert .she refused her HS meds, system review, resident has history of unsteady gait, resident recently admitted to the facility, call light within reach, resident weak with poor appetite, DON and NP notified. Record review of Resident #1 neuro checks, dated 03/28/24 revealed, her vitals were checked twice at 8:00 PM and 8:15 PM. Record review of neuro checks revealed: BP 151/90 (High), HR 87, SPO2 100, TEMP 98.0 at 8:00 PM. Record review of neuro checks at 8:15 PM revealed: BP 168/90 (high), HR87, SP02 100, TEMP 97.0 Interview on 03/30/24 at 7:00 AM with LVN L revealed, Resident #1 was found on the floor by her family member and had a knot on her forehead. LVN L completed assessment and on Resident #1. LVN L revealed Resident #1 was not able to tell what occurred. LVN L revealed Resident #1 was sent out to the hospital. Interview on 03/30/24 at 12:15 PM with the DON revealed Resident #1's unwitnessed fall was not a reportable event. The DON revealed Resident#01 did not sustain injury and was not in pain. The DON revealed, facility policy was followed and completed. The DON revealed the Administrator was the Abuse Coordinator. The DON revealed she called the hospital and checked on Resident #1 and no concerns were reported. Observation and interview on 04/01/24 at 4:30 PM at the hospital with Resident #1 revealed she knew she had a fall, but she did not remember what happened. Interview and record review on 04/01/24 at 5:03 PM with the Hospital Nurse revealed, Resident #1 was admitted because of a fall. Hospital Nurse revealed Resident #1's MRI revealed new bleeding on the brain that came from the fall. Interview on 04/01/24 at 7:10 PM with the DON revealed she did not believe this was a reportable event because the resident did not have serious injury such as a laceration. The DON revealed by a reportable event not being reported can cause the residents to be abused. Interview on 04/01/24 at 8:45 PM with the Administrator revealed she did not think Resident #1's accident on 03/28/24 was a reportable event because the resident was not seriously injured. The Administrator revealed the facility did not report the incident because it did not meet the criteria for reporting since the resident did not have a serious injury. Record review of the facility's Incident and Reportable Event Management policy, dated 09/14/23, reflected: 1) Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source .are reported immediately, but no later than 2 hours . 675650 Page 2 of 5 675650 04/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4) Report the results of all investigations to the Executive Director or his or her designee and to other officials in accordance with State law, including the State Survey Agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The agency policy goes on to define injuries of unknown source as Any injury should be classified as an injury of unknown source when both of the following conditions are met: The source of injury was not observed by any person, or the source of the injury could not be explained by the patient. .not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency . 675650 Page 3 of 5 675650 04/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 2 of 2 medication carts (secured unit and general population hall) reviewed for drug storage. LVN V and unidentified staff left 2 medication carts (secured unit and general population hall) unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings include: Observation on 03/30/24 at 6:15 AM revealed the general population medication cart was unlocked in front of the nursing station. Observation of the general population medication cart revealed the drawers facing outward and key mechanism popped out with a display of a red mark. Observed staff down the other end of the hallway. Observation on 03/30/24 at 6:30 AM revealed, the secure unit medication cart was unlocked on the secure unit. Observation of the secure unit medication cart revealed the drawers facing outward and key mechanism popped out with a display of a red mark. Observed no staff in sight of the medication cart. Interview on 04/01/24 at 6:35 AM with LVN V revealed, this was his medication cart and he was taking a resident's blood pressure and coming back to the cart. LVN L revealed the medication cart should always be locked. LVN V revealed residents could get into the medication cart and take medication not prescribed to that resident. Observation on 03/30/24 at 6:45 AM with Medical Records Director revealed, she locked the medication cart when she walked by the medication cart located in the general population. Interview on 03/30/24 at 6:47 AM with The Medical Records Director revealed, she noticed the medication cart was unlocked and locked it. The medical Records Director revealed she did not know the facility policy on administration of medication. Interview on 03/30/24 at 7:00 AM with LVN L revealed the medication cart should be locked when not in use. LVN L revealed residents could get into the cart and self-medicate. Observation on 03/30/24 at 7:04 AM revealed prescription medications and over the counter medications were in the medication cart. Interview on 03/30/24 at 7:48 AM with the DON revealed, nurses are responsible for the medication cart, and it should be locked to prevent residents from going into it. The DON was asked about the medication cart in general population and who was responsible for the medication cart. The DON did not reveal the staff that worked on the medication cart in general population. 675650 Page 4 of 5 675650 04/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0761 Level of Harm - Minimal harm or potential for actual harm Interview on 04/01/24 at 7:15 PM with LVN E revealed, the medication cart was always locked to protect residents from taking prescribed medications out of the cart. Interview on 04/01/24 at 8:45 PM with Administrator revealed nursing staff are expected to follow facility policy and keep the medication carts locked and secured. Residents Affected - Some Record review of facility policy titled, Medication Administration Guide revised 06/2023 reflected, It is the designated staff member's responsibility to maintain the possession of the keys and security of the medication cart. The medication cart always needed to be securely locked when it is out of the nurses visual. 675650 Page 5 of 5