Garden Terrace Healthcare Center of Fort Worth

Inspectors wroteBased on interviews and record reviews, the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed. The facility failed to obtain resident consent before identifiable health information was sent out via email by the SW to nonresidents. This failure placed residents at risk of personal health Information exposed.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 2 (Residents #15 and #81) of 2 residents reviewed for peripheral intravenous care. 1. The facility failed to attach Resident #81's needleless connector (connects to the end of a catheter to delivery IV therapy) to the IV every seven days as indicated in the physician's orders. (A midline is a long flexible tube that is inserted into the vein in the upper arm to administer medication or fluids intravenously) and failed to date the IV dressing. 2. RN G failed to disinfect the midline catheter prior to securing the needleless connector on the IV for Resident #81. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for three (Residents #18, #25, and #133) of ten residents reviewed for oxygen: The facility failed to ensure the humidifier water was changed according to the facility policy for Residents #18, #25 , and #133 and failed to ensure oxygen tubing was changed weekly per facility policy for Residents #18 and #25. This deficient practice could affect residents who received oxygen therapy by causing them to receive incorrect or inadequate oxygen support and could expose them increased infection risk, resulting in infections and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for storage of drugs and biologicals under proper temperature controls, and provide separately locked, permanently affixed compartments for storage of medications for 2 (med rooms A and B) of 2 reviewed for medication storage. 1. The facility failed to ensure medication rooms A and B were clean and well-lit. 2. The facility failed to ensure the fridge/freezer was at an appropriate temperature, which caused medications to freeze over in medication room A. This deficient practice could affect residents prescribed medications in the facility and place them at risk of receiving compromised or contaminated medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure kitchen staff had a hair net on while in the kitchen. 2. The facility failed to ensure food items in the dry storage were dated, labeled, and securely stored. 3. The facility failed to ensure two cans of canned goods were free from dents. 4. The facility failed to ensure food items in the walk-in freezer were labeled, dated, and secured. 5. The facility failed to ensure a metal container of melted fat held on the gas stove was properly covered and dated. 6. The facility failed to ensure cleaning equipment was not placed against clean dishes. 7. The facility failed to ensure nourishment refrigerators were free from cross-contamination? 8. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 4 of ten (Resident #15, #18, and #25) reviewed for infection control. 1. LVN F failed to ensure PPE was worn for residents on EBP (Residents #15 and #25). 2. CNA J failed to perform hand hygiene during breakfast in A hall dining room and after assisting Resident #18. The failures could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services for 2 (med rooms A and B) of 2 reviewed for medication storage 1. The facility failed to dispose of expired medications. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Food that accommodates resident allergies, intolerances, and preferences for one (Resident #131) of 3 residents reviewed for food preferences. The facility provided Resident #131 a lunch meal that contained meat in it, which did not match her vegetarian preferences. This failure could affect residents who ate meals from the facility's only kitchen by placing them at risk of not having their choices and food preferences accommodated, possible weight loss, and a diminished quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 of 5 residents (Resident #1, #3, #5, #7, #9) reviewed for respiratory care. The facility failed to ensure Resident #1, #3, #5, #7, and #9's oxygen tubing was labeled and dated. The facility failed to ensure Resident #1, #3, and #9's CPAP tubing were dated and properly stored when they weren't in use. These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status (deterioration in health in either life-threatening condition) for 1 (Resident #1) of 37 residents reviewed for physician notification. The facility failed to ensure the physician was notified after Resident #1 was alleged to have been dropped mid-transfer. After being taking to the hospital during dialysis on 11/27/23 the resident was reported to have multiple fractured ribs and a sternum fracture. On 11/24/23 resident family member reported to the nurse that the resident told her she was dropped, and her chest was hurting. RN K gave pain medication but failed to do a full body assessment nor did she report it to the physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from neglect and failed to develop and implement written policies and procedures that prohibit and prevent neglect for 1 of 37 residents (Resident # 1) reviewed for neglect. RN K failed to report and assess Resident #1's fall to the facility when the family alleged the resident was dropped during transfer. The facility was unaware the resident had fractured ribs and sternum until Resident #1 was sent to the hospital due to unrelated concern of low blood pressure, three days after the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/14/23. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents' environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident # 1 of 37 residents (Resident#1) reviewed for adequate supervision accident and hazards. RN K failed to report Resident #1's fall to the facility and failed to assess Resident #1 when the family alleged the resident was dropped during transfer. The facility was unaware the resident had fractured ribs and sternum until Resident #1 was sent to the hospital due to unrelated concern of low blood pressure, three days after the incident. This resulted in the residents at risk for delay in assessment in treatment, placing them at risk for further harm, injury, or death. An Immediate Jeopardy (IJ) was identified on 12/14/23. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 medication carts (Southeast nurse's cart) and 2 (Residents #2 and #7) of 8 residents reviewed for pharmacy services. 1. The facility did not ensure RN K, counted the home narcotic drugs (narcotics that were brought in from the family) every shift change. On 11/30/2023 charge nurse A and RN B counted their meds at the beginning of shift change and there was a discrepancy of 10 tablets. 2. The facility failed to ensure RN M administered the correct medication dosage to Resident #7. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #7) of 8 residents reviewed for medication storage. The facility failed to ensure medications were monitored during medication pass, leaving medications exposed on the medication cart when RN M turned away. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for kitchen sanitation in the facility's only kitchen observed for kitchen sanitation. 1. The facility failed to ensure kitchen staff wore appropriate hair and beard restraints. 2. The facility failed to ensure food items in the refrigerator were dated, labeled and sealed appropriately. These failures could affect residents by placing them at risk for food-borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 resident (Resident #12) out of 6 residents reviewed for care plans in that: Resident #12 did not have a baseline care plan created within 48 hours when she was first admitted to the facility. A past noncompliance was determined to have existed from 09/27/23 through 09/30/23. The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice affects residents who are new admissions and could result in decreased quality of care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure staff followed their infection prevention policy for 1 (Resident #11) of 3 residents and 2 (Treatment Carts A and B) of 6 sharps containers reviewed for infection control. 1. Staff failed to don the appropriate PPE when providing care to Resident #11 who was on Enhanced Barrier Precautions 2. Staff failed to change out the sharps containers on Treatment carts A and B before they became over filled. Each container has a Do Not Fill Past line, at which time it should be changed out to ensure the safety flap continues to work properly. These failures could place the residents at risk of exposure to infectious agents.