Inspection·April 27, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident, resident representative and send a copy to the Office of the State Long-Term Care Ombudsman, of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one (Resident #1) of four residents reviewed for discharge. The facility failed to notify Resident #1, the resident representative, and the Ombudsman in writing of the transfer/discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could put residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Review of Resident #1's facesheet provided 04/27/23 revealed the resident was admitted to the facility on [DATE]. His diagnoses included post traumatic stress disorder, narcissistic personality disorder, major depressive disorder, anxiety disorder, and pain. Review of Resident #1's nurses noted dated 03/27/23 reflected the following: 8:08 AM - This LVN was on the unit at time of incident, noted staff running out of room stating he was trying to choke her, he had her hands around her throat and had pushed her against the wall 1:16 PM - Referral for Med Management with [behavioral health services] completed today. Telehealth appointment done today with [PNP] recommending inpatient treatment. 5:04 PM - Report was called to VA ER via [transport] and VA is expecting wife to accompany resident left to go to VA ER at this time, wife did not take any clothes or personal belongings. Interview on 04/27/23 at 3:45 PM with the Social Worker revealed psych services were set up for Resident #1 because he was having behaviors such as assaulting staff. The Social Worker stated the behavioral health services said Resident #1 needed to be sent out for inpatient treatment due to being a danger to himself and others. The Social Worker said the Administrator was the one who handled Resident's #1's discharge. Interview on 04/27/23 at 4:49 PM with the DON revealed Resident #1 was discharged to the VA ER (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 2 Event ID: 745019 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 745019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE James L West Center for Dementia Care 1111 Summit Ave Fort Worth, TX 76102 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)