Dfw Nursing & Rehab
DFW Nursing & Rehab in Fort Worth, TX — inspection on May 20, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect, by 5/20/2025.
Started 5/19/2025.
DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors.
Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated.
Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee.
Started 5/19/2025 Process will be on going.
In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete.
Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management.
Started 5/19/2025.
Process will be on going .
The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect.
Started 5/19/2025 In-service will be on going.
QAPI meeting will be held monthly, and findings discussed.
The DON will monitor the effectiveness of interventions will be ongoing.
A pre/posttest on abuse and neglect will be on going starting 5/20/2025.
Started 5/20/2025.
The facility is still looking for proper placement of resident .
Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Review the following:
Regulation: F-600
S483.12 Freedom from Abuse, Neglect, and Exploitation
455881
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 455881 B.
Wing 05/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104
Highlight the deficient practice and specifics of the citation.
Facility Policy and Practice
Facility's Action Plan regarding the deficiency.
Facility's Policies and Procedures related to the deficiency.
Facility's Checklists and Monitoring tools used to verify compliance.
Facility's Abuse investigation procedure and documentation process.
Record of Training
Complete Record of In-service Training and Attendance Form. Be sure that all participants sign in.
Monitoring of the POR included the following:
Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, MDS Nurse, nurses, CMAs, and CNAs: LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's policy on abuse/sexual abuse, neglect, and exploitation starting on 5/19/25-5/20/25.
All staff were able to identify abuse/sexual abuse, neglect, and exploitation, state when to report it, and who to report it to.
All staff were able to state the updated procedure for sexual abuse which included removing any residents who exhibited inappropriate sexual behaviors from the area, placing them on 1 to 1 supervision until further advised, immediately reporting the behaviors to the MD, DON, and family, and following any new orders.
The nurses were able to state that all behaviors had to be documented and reported to the DON.
The SSD was able to state that she was responsible for monitoring documentation for any changes in residents' behaviors and ensure the care plans were updated and assist in the discharge process as necessary.
The Administrator and DON were able to state it was the facility's expectation to identify, report, and investigation any suspected or alleged abuse/sexual abuse, neglect, and exploitation.
The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of interventions put in place.
455881
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 455881 B.
Wing 05/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104
The facility failed to ensure Resident #2 received adequate supervision to prevent a serious accident when the resident went to the hospital on 2/15/25 and was found to have marijuana in his system, after the facility was made aware that he was bringing nonprescription drugs into the facility.
- Resident #2 was assessed and found to not have any signs or symptoms of current drug use.
Date completed 5/19/25. MD was notified of the use of illegal drugs related to the past incident.
Resident was drug tested on [DATE].
Drug test was negative.
- All residents have the potential to be affected although no other residents have been affected.
- All residents will be in-serviced on the facility policy regarding illegal drug use. (5/20/2025).
All residents will be assessed upon return from any leave from the facility to look for signs and symptoms of illegal drug use to include limpness on both sides of body, pinpoint pupils, confusion, and difficulty talking.
All nursing staff will be in-serviced to perform and document the assessment upon return and if any signs and symptoms are noted the Administrator and DON will be notified, and the facility will follow the illegal drug use policy. 5/20/2025
- The DON/designee will monitor the documentation for each resident return to ensure the assessments are
complete.
This will be completed on 5/20/25.
- Resident is still being discharged pending acceptance.
- The DON/designee will monitor the effectiveness of assessments completed of residents .
- QAPI meeting will be held monthly, and findings will be discussed.
- A pre/posttest will be completed by staff on signs/symptoms of drug use Completion 5/20/2025 and
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN,
ongoing.
new staff, or staff that has not participated in training.
Monitoring of the POR included the following:
08/27/2025
N o. 0938-0391
IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
05/20/2025 Dfw Nursing & Rehab 900 W Leuda St
jeopardy to resident health or safety
Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, nurses, CMAs, and CNAs : LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's drug policy and recognizing and reporting any s/sx of drug use in residents and staff starting on 5/19/25-5/20/25.
All staff were able to state drugs were not tolerated at the facility by staff or residents, and residents could only have drugs and alcohol if ordered by the MD and administered by a nurse.
All staff were able to state residents would be monitored for s/sx of drug use in general and when they went out into the community and returned to the facility.
All staff were able to provide s/sx of drug use and stated if residents exhibited any of the s/sx it would be reported to the charge nurse and administration immediately.
The nurses were able to state s/sx of drug use and residents who exhibited any s/sx would be assessed and the MD, DON, Administrator, and family would be notified, and any new orders followed.
The nurses were able to state all assessments and incidents would be documented .
The DON stated there was a town hall meeting held with the residents to educate them on the facility's drug policy.
The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of all interventions put in place.
Observation, interview and record review on 5/20/25 from 3:00 PM-4:00 PM, of Residents #2, #3, #4, #6, and #7, who were all at risk for accidents due to inadequate supervision.
Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or concerns for the potential of accidents that could cause serious injury.
Observation of the residents revealed no s/sx of drug use, intoxication, or harm from inadequate supervision.
Interviews with residents and/or RPs revealed no concerns for inadequate supervision or harm.
Further interview with the residents revealed they were aware of the facility's drug policy and understood illegal and nonprescription drugs were not allowed at the facility.
Record review of an in-service titled Illegal Drug Use, dated 5/19/25, reflected all staff were educated on the facility's drug policy and on recognizing and reporting any s/sx of drug use in residents and staff.
Record review of an in-service titled Assessment of signs and symptoms of drugs, dated 5/20/25, reflected the DON, ADON, and all nurses were educated on recognizing, assessing for, and reporting any s/sx of drug use.
Record review of documents provided by the Regional Nurse Consultant, titled F-F689-Pre/Post Test, dated 5/20/25, reflected all staff were tested over their knowledge on recognizing and reporting s/sx of drug use.
Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Plan Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in quality of care.
Record review of document provided by the Regional Nurse Consultant, dated 5/20/25, reflected Resident #2 had a negative drug screening.
08/27/2025
N o. 0938-0391
IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
05/20/2025 Dfw Nursing & Rehab 900 W Leuda St
jeopardy to resident health or safety
The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM.
The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
08/27/2025