Garden Terrace Healthcare Center of Fort Worth

In the surveyor’s words

From the most serious findings on record at Garden Terrace Healthcare Center of Fort Worth, in the surveyor’s own words.

• Immediate jeopardy, patternF880Dec 15, 2021

  Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 staff reviewed (CNA E , CNA F and CNA G) for infection. 1. The facility failed to protect residents from exposure to COVID-19 when they allowed CNA E to work in the facility after she stated she had symptoms of COVID-19. Two to three days later 7(Resident #1, #2, #3, #4, #5, #6, and #7) residents and 2(CNA H and LVN T)2 staff members tested positive for COVID-19. 2. […]

• Immediate jeopardy, isolatedF580Dec 15, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF600Dec 15, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Dec 15, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF678Aug 22, 2022

  Based on interview and record review the facility failed to ensure personnel provided basic life support, which included CPR (Cardio- Pulmonary Resuscitation), to a resident who required such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directive for 1 of 5 residents (Resident #1) reviewed for CPR. PTA A failed to initiate CPR for a resident who was unresponsive with a code status of Full Code. The resident expired in the facility. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents who could need CPR at risk of death. […]