Health inspection·February 12, 2026

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 interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to develop a care plan to address Resident #1's and Resident #2's inability to use a call light. This failure could have placed residents at risk of not having their needs identified and met. The findings were: Resident #1Record review of Resident #1's face sheet reflected a [AGE] year old female resident with an admission date of 4/27/2023 with diagnoses that included: unspecified dementia (disease affecting memory, thinking, and the ability to perform daily activities), generalized muscle weakness, heart failure, schizoaffective disorder (mental disorder characterized by psychosis and mood disorder), and anxiety disorder.Record review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 was not assessed for a BIMS score because she was rarely/never understood. The BIMS reflected she had short-term and long-term memory problems. Her cognitive skills for daily decision making were reflected as moderately impaired with decisions poor and cues/supervision required. Her cognitive assessment reflected inattention and altered level of consciousness (vigilant, lethargic, stuporous, and/or comatose). The MDS reflected Resident #1 was dependent on staff for all self-care functional abilities. The MDS reflected Resident #1 was dependent on staff for all mobility functional abilities except for toileting transfers and walking 10 feet which were not applicable.Record review of the care plan dated 12-29-2025 reflected Resident #1 had an activity of daily living self-care performance deficit and an intervention included to encourage the resident to use the call light for assistance. The care plan did not reflect Resident #1's inability to use the call light and provide alternatives. Resident #2Record review of Resident #2's face sheet reflected a [AGE] year old female last admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial weakness and complete paralysis following a stroke), generalized muscle weakness, acute kidney failure, other lack of coordination, cognitive communication deficit (affects a person's ability to communicate effectively), memory deficit following cerebral infarction (stroke), and unspecified dementia (disease affecting memory, thinking, and the ability to perform daily activities).Record review of Resident #2's Significant Change MDS assessment dated [DATE], reflected a BIMS assessment was not conducted as resident was rarely/never understood. The MDS reflected Resident #2 had functional limitation in range of motion in an upper extremity on one side. The MDS reflected Resident #2 was dependent on staff to do all of the effort for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS reflected Resident #2 required substantial/maximal assistance for eating. The MDS Page 1 of 3 675650 675650 02/12/2026 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reflected Resident #2 required substantial/maximal assistance for the following activities: roll left and right, sit to lying, lying to sitting on side of the bed, moving from sitting to standing, and transferring from chair/bed-to-bed transfer. The MDS reflected she was completely dependent on staff for tub/shower transfers and that toilet transfers and walking 10 feet were not applicable.Record review of Resident #2's care plan initiated 8-28-2025 reflected Resident #2 was at risk for falls and an intervention included that her call light should be within reach. Her care plan did not reflect her inability to use a call light and did not provide alternative interventions for the use of the call light.In an interview on 02/11/2026 at 08:05 a.m., RN A stated that Resident #1 could not press her call light due to her cognitive status. He stated that she was unable to remember and unable to know that she had to use the call light. He stated that Resident #1 was at risk of falls and not getting her immediate needs met if she was unable to use a call light and did not have alternatives in place.In an interview on 02/11/2026 at 08:13 a.m., CNA B stated that Resident #1 was not able to use her call light and did not yell or call out for assistance, but that Resident #1 typically had a sitter at the bedside from around noon to 6 p.m. each day. CNA B stated that Resident #1 could not use her call light because of her mental status. She stated that Resident #1 would not be at risk if she could not use a call light or have planned alternatives because staff were aware of her inability to use the call light and were monitoring her frequently.In an observation on 02/11/2026 at 08:22 a.m., Resident #2 was observed in bed awake. She was observed as nonverbal, and she appeared confused and unable to follow commands. She did not respond when asked about where her call light was.In an interview on 02/11/2026 at 08:30 a.m., LVN C stated that Resident #2 had used her call light before she experienced a decline and was placed on hospice (date unknown), but that since that time she had not been able to use the call light. She stated that the aides know they have to check on Resident #2 because she cannot remember to use the call light. She stated that if Resident #2 could not use a call light and did not have an alternative, she would be at risk for falls.In an interview on 02/11/2026 at 08:40 a.m., CNA D stated that Resident #2 had never pushed the call light in the past month that she had worked at the facility. CNA D stated she did not think Resident #2 was able to understand using the call light. She stated staff made frequent rounds and left Resident #2's door open because they were aware she could not use her call light. She stated that if a resident could not use a call light and there were no alternative interventions, the resident could potentially fall and if they choked, they could not call for help.In an interview on 02/12/2026 at 12:45 p.m., the DON stated that Resident #1 had not been able to use her call light since she had begun working at the facility in 2023. She stated that Resident #1 typically had a sitter in her room from approximately 10 a.m. until 7 p.m. The DON stated that Resident #1 had not had any falls or injuries in the past year that she was aware of. The DON stated that Resident #2 had not been able to use her call light since her admission in 2024 due to her advanced dementia. She stated that Resident #2 had not had any falls or injuries in the past year that she was aware of. The DON stated that if a resident could not use a call light the facility should put a different intervention in the care plan, such as leaving the resident's door open or performing more frequent rounding. She stated that all nurses, the DON, and the MDS nurse were responsible for updating the care plan. She stated that if the care plan was not updated to reflect a resident's inability to use a call light it would be, a safety concern to the resident.In an interview on 02/12/2026 at 01:15 p.m., the ADM stated that Resident #1 and Resident #2 were unable to use their call lights. She stated that the facility policy stated that if a resident could not use the call light, alternatives including things such as leaving the doors open, moving the resident closer to the nurse's station, or more frequent monitoring could be used. She 675650 Page 2 of 3 675650 02/12/2026 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that the MDS coordinator was responsible for updating the care plan with alternative interventions. She stated that updating the care plan with these alternative interventions was important so that staff were aware of what they needed to follow for the patients.Review of the facility policy titled, Resident Call System with reviewed date of 12/23/2025 stated, The call light should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative.Review of the facility policy titled, Comprehensive Care Plans and Revisions with reviewed date of 08/29/2025 stated, the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. 675650 Page 3 of 3