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 (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 5 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 04/01/2024 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)