Health inspection·July 18, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 10 residents (#1, #2) observed for dignity during lunch service: RN A and CNA B stood up to feed Residents #1 and #2 during lunch. This deficient practice could affect 10 residents that reside in memory care. The findings included: Review of Resident #1's admission Record undated revealed he was admitted to the facility on [DATE] with principal diagnoses of CENTRAL DISLOCATION OF RIGHT HIP, SUBSEQUENT ENCOUNTER; DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE (severe mental health conditions that cause abnormal thinking and perceptions), MOOD DISTURBANCE (mental health conditions affecting mood), AND ANXIETY and ALZHEIMER'S DISEASE, UNSPECIFIED. Review of Resident #2's admission Record undated revealed [AGE] year-old male admitted on [DATE] with a primary diagnoses of METABOLIC ENCEPHALOPATHY (condition where brain function is disturbed due to different diseases); ALZHEIMER'S DISEASE WITH LATE ONSET. Review of Resident #1's Care Plan dated 07/09/2024 revealed; ADL 's Mobility; Goal: Resident will be able to: (Specify); Interventions *EATING; The resident will be able to (Specify) Review of Resident #2's Care Plan dated 02/29/2024 revealed; ADL Goal; Intervention: EATING: The Review of Resident #1's Resident Assessment and Care Screening dated 07/14/2024 revealed; No BIMS score entered for Resident #1. Section GG- Functional Abilities and Goals; Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Resident admission performance: 03 Partial/Moderate assistance- Helper does LESS THAN HALF the effort. Observation on 07/18/2024 at 11:42 am, in the memory care day room revealed RN A assisting Resident #1 with lunch. He stood next to him holding the eating utensil for Resident #1 offering him food. Page 1 of 4 675650 675650 07/18/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 07/18/2024 at 11:56 am, in the memory care day room revealed CNA B assisting Resident #2 with his lunch. He walked over to Resident #2 encouraged him to eat then picked up the eating utensil and offered Resident #2 his food. Interview on 07/18/2024 at 1:53 pm with CNA B reflected, he was standing when feeding Resident #2 in order to go back and forth between residents for assistance. He stated that you sit next to the resident to be on the same level and watch how they eat. Interview on 07/18/2024 at 1:57 pm with RN A reflected, he was standing to feed the resident because the residents in memory care were lit (not calm) and he needed to stand to be able to move around the area if he was needed. He stated that he knew he was supposed to sit down when assisting residents with meals. Review of facility policy and procedure on Feeding a Resident dated revised 08/24/2023 revealed Procedure .3. Sit to assist resident with eating. 675650 Page 2 of 4 675650 07/18/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (Resident #3) of four residents who are perscribed medication reviewed for accidents and supervision. The facility failed to ensure RN A and CNA B provided Resident #3 adequate supervision after leaving syringes in the trash can of the resident's room, exposed and within reach of confused residents. This failure could place resident at risk for accidents and injury. Findings included: Review of Resident #3's electronic admissions report undated reflected a [AGE] year-old-female admitted to the facility on [DATE]. Primary diagnosis SUBLUXATION OF C4/C5 CERVICAL VERTEBRAE , SUBSEQUENT ENCOUNTER (associated with an increase in facet joint gap/distraction), UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE Review of Resident #3's care plan revised on [DATE] reflectedFocus: The resident/is has potential to be verbally aggressive r/t Dementia, ineffective coping skills, poor impulse control. Goals: The resident will demonstrate effective coping skills. Intervention: Administer medications as ordered. Review of Resident #3's MDS Resident Assessment and Care Screening dated [DATE] reflected; Section C- Cognitive Patterns- Should Brief Interview for Mental Status be Conducted. 0- No, resdient is rarely/never understood. Review of Resident #3's doctors orders dated [DATE] reflected; ABH Gel (Ativan, Benadryl, Haldol) Gel apply to wrist topically every 4 hours for Anxiety Observation/Interview on [DATE] at 11:11 a.m. revealed; in the secure unit's common area (area where a group of residents share the space not owned by a specific resident) observation of 10 residents and CNA B, Resident #3 seated in a recliner with footrest up in a reclining postion. Resident #3s eyes were closed. Resdient #5 aroused and used her right hand to move the [NAME] and lower the footrest placing her in a sitted postion. CNA B assisted Resident #3 to her wheelchair. Once Resident #3 was moved to a table with other residents , observation of the within reach enviorment revealed trashcan A with a clear plasic trashliner. In trashcan A, there were two red neddleless syringes. Continued enviormental observation of the common area revealed trashcan B (located by the exit door) with various items of trash on top of a visiable red syringe type item. Interview with CNA B reflected the red syringe is used to apply gel on the residents wrist to calm them down. He stated the nurse is the person that applied the medication. Interview and observation on [DATE] at 11:17 am with RN A revealed; the syringes are used to apply the bio gel to residents for anxiety. RN A stated he did not know who was responsible for disposing the items in the trash. RN A immedialy removed the trash liners from each trashcan and stated that it should not be placed in the trashcan. RN A stated the risk to the resdents was they could pick it up and eat it. 675650 Page 3 of 4 675650 07/18/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 2:19 pm with MDS Coodinator reflected; the risk to the residents was the residents could get the syringe out of the trash. She stated that the expecation was once used they are placed in the [NAME] container. Review of policy Disposal/Destruction of Expired or Discontinued Medication revised date [DATE] refected; Facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable enviormental regulations. 675650 Page 4 of 4