Dfw Nursing & Rehab

F-F600 | Free from Neglect - The facility failed to ensure Resident #1 was free from neglect when he was not provided appropriate good or services to prevent his sexually inappropriate behaviors to potentially cause harm to himself and to others.

2. Identification of Residents Affected or Likely to be Affected:

The DON, Social Services Director, and designee(s) interviewed/assessed residents all residents for potential abuse by conducting safe surveys on each resident. Concerns were identified. Concerns identified were resident keeps staring at them and touching his privates-3 residents). (Completion Date: 4/23/2025):

The following actions were taken to prevent Resident # 1 from perpetrating additional abusive behaviors. Resident evaluated by primary care provider on 5/14/25 and provided a medication update.

Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted on 5/20/2025. Psych consult provided (5/23/2025).

Resident will not be seated near female resident(s) at activities, dining, etc . when at all possible.

IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident.

3. Actions to Prevent Occurrence/Recurrence:

The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/20/2025)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0600 Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.

Level of Harm - Immediate Abuse investigation procedure and documentation process were reviewed and revised. Administrator and jeopardy to resident health or DON educated all staff on changes. safety Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies. Residents Affected - Some Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting. Note: The nursing home is disputing this citation. 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0600 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, Level of Harm - Immediate involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical jeopardy to resident health or symptoms. safety Intent S483.12(a)(1) Residents Affected - Some Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Note: The nursing home is disputing this citation. 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 5/08/25at 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 all behaviors had to be documented and reported to the DON. The SSD was able to state 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 investigate 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0600 Observation, interview and record review on 5/20/25 at 3:00 PM-4:00 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11, who were all at risk for abuse, neglect, and exploitation , revealed no further Level of Harm - Immediate concerns. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or jeopardy to resident health or psychosocial status or a lack in necessary goods and services. Observation of the residents revealed no safety signs of abuse or neglect. Interviews with residents and/or RPs revealed no concerns for abuse, neglect, or exploitation. Residents Affected - Some

Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected all staff were educated on Note: The nursing home is the facility's policy on recognizing and reporting abuse and neglect. disputing this citation.

Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected the Administrator, DON, and SSD were educated on implementing the facility's policy to assess, investigate, and report any alleged abuse and neglect.

Record review of an in-service titled Sexual Assault, dated 5/20/25, reflected all staff were educated on recognizing and reporting any signs of sexual abuse and inappropriate sexual behaviors.

Record review of documents provided by the Regional Nurse Consultant titled Abuse, Neglect, and Exploitation-Pre/Post Test, dated 5/20/25, reflected the DON tested all staff over their knowledge on recognizing and reporting abuse, neglect, and exploitation.

Record review of a progress note, dated 5/20/25 at 11:25 AM, reflected Resident #1 was connected to psychiatric services to address sexual behaviors .

Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Pla Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in neglect.

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.

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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

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)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45054 jeopardy to resident health or safety Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and Residents Affected - Some misappropriation of resident property for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. Note: The nursing home is disputing this citation. -The facility failed to implement policies and procedures to ensure Resident #1 was free from deprivation of goods and services abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and in-service staff on measures to properly handle

the behaviors to prevent Resident #1 from sexually abusing others.

An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern 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 .

These failures could place residents at an increased risk for abuse and neglect.

Findings include:

Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE REDACTED]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels, chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure).

Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors.

Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.

Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following:

HPI:

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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

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)

F 0607 LTC on therapy

Level of Harm - Immediate Today: jeopardy to resident health or safety . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer Residents Affected - Some safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors. Note: The nursing home is disputing this citation. .

Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following:

[SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt.

Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following:

[DON] was notified by [Activity Director] that [Resident #1] has 'inappropriately touched' a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware.

Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following:

[Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities.

Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time.

Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents.

Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic.

Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0607 -Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25.

Level of Harm - Immediate Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric jeopardy to resident health or services. safety

In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident Residents Affected - Some #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to Note: The nursing home is admission. The DON stated per regional managers, the facility did not discriminate against residents disputing this citation. regarding criminal background. The Administrator and the DON failed to mention Resident #1 was involved

in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor

during this interview.

In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who

she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1.

In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated

she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0607 In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor Level of Harm - Immediate was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her jeopardy to resident health or the students were in the dining room areas doing an activity with the residents when one of the students ran safety out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, Residents Affected - Some they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did Note: The nursing home is not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate disputing this citation. behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw

the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation, report it to the state agency, or notify law enforcement. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place

the residents at risk of being harmed.

In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to

the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0607 In an interview on 5/19/25 at 9:26 AM, the Activity Director stated students from the local high school would come to the facility twice a month to do activities with the residents. The Activity Director stated on 4/23/25, Level of Harm - Immediate the students were at the facility doing an activity with the residents in the dining area. He stated a student jeopardy to resident health or came up to him visibly upset then pointed at Resident #1 and stated he grabbed one of the student's thighs. safety The Activity Director stated he saw the student run out of the area but did not know her name and the other students refused to identify her. The Activity Director stated he immediately removed Resident #1 from the Residents Affected - Some area until the students left the facility. He stated he reported the incident to the Administrator and the DON.

The Activity Director stated Resident #1 was placed on 1 to 1 supervision for some time, but he was not sure Note: The nursing home is what else was done. He stated the Administrator did not ban the students from the facility because he was disputing this citation. still expecting them to show up; however, they never returned. The Activity Director stated he heard Resident #1 was sexually inappropriate with the aides, but he never heard of Resident #1 doing anything to other residents.

Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated after the incident

she did not in-service the staff on abuse/neglect and sexually inappropriate behaviors. The DON stated the staff received routine trainings and in-services as needed on abuse and neglect, but she did not know if they received trainings specifically regarding sexual behaviors other than upon hire. The DON stated staff knew to document daily on Resident #1 and the staff who were assigned to do Q 15-miute checks were informed about the incident and knew what to monitor for; however, this was not documented as an in-service. The Administrator stated he had a meeting with management regarding the incident, but it was not documented.

The Administrator stated he had a memo typed up that had not been sent out yet because he was waiting to see if the students would return to the facility. He did not state what information was included in the memo .

The DON stated not having effective interventions in place, placed residents and visitors at risk of being sexually abused. She stated this also placed Resident #1 at risk of being harmed because he could be sexually inappropriate towards someone who could hurt him.

In an interview on 5/19/25 at 4:36 PM, Resident #1's RP stated the facility notified her sometime last month to inform her the resident was being discharged to a group home for being sexually inappropriate with a student that was visiting the facility. The RP stated she was aware Resident #1 exhibited sexually inappropriate behaviors from his previous facility; however, he could not help it due to his dementia. The RP stated the last thing she heard from the facility was Resident #1 was placed on 1 to 1 supervision and was told she would have to pay for it to continue. The RP stated she was informed she could not afford to pay, and she also could not bring Resident #1 home with her, and that was the last time she heard from them.

In an observation and interview on 5/19/25 at 4:52 PM, revealed Resident #1 was sitting in a wheelchair in his room. He was dressed and well-groomed . Resident #1 stated he had just returned to the facility from dialysis and was tired. Resident #1 stated he was fine then refused to answer any other questions. This state surveyor was unable to obtain any information from Resident #1 regarding the incident.

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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

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)

F 0607 In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was Level of Harm - Immediate showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she jeopardy to resident health or placed the resident on 2-person assist with care but there was not always an extra staff to help when safety needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came Residents Affected - Some to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and Note: The nursing home is DON . disputing this citation.

Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part

the following:

Policy Statement:

Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Policy Interpretation and Implementation:

As part of the resident abuse prevention, the administration will:

1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

.

3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.

4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

5. Implement measures to address factors that may lead to abusive situations, for example:

a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation.

b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and

c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.

6. Identify and assess all possible incidents of abuse;

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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

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)

F 0607 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements;

Level of Harm - Immediate 8. Protect residents during abuse investigations; jeopardy to resident health or safety 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and Residents Affected - Some 10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. Note: The nursing home is disputing this citation. This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 05/19/25 at 3:25 PM

The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM:

[Nursing Facility]

1.

F-F607)

S483.12 Freedom from Abuse, Neglect, and Exploitation

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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

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)

F 0607 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, Level of Harm - Immediate involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical jeopardy to resident health or symptoms. safety Intent S483.12(a)(1) Residents Affected - Some Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Note: The nursing home is disputing this citation. 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.

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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

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)

F 0607 Observation, interview, and record review on 5/20/25, 3:00 PM-4:00 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, who were all at risk for abuse, neglect, and exploitation, revealed no further Level of Harm - Immediate concerns. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or jeopardy to resident health or psychosocial status or a lack in necessary goods and services. Observation of the residents revealed no safety signs of abuse or neglect. Interviews with residents and/or RPs revealed no concerns for abuse, neglect, or exploitation. Residents Affected - Some

Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected all staff were educated on Note: The nursing home is the facility's policy on recognizing and reporting abuse and neglect. disputing this citation.

Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected the Administrator, DON, and SSD were educated on implementing the facility's policy to assess, investigate, and report any alleged abuse and neglect.

Record review of an in-service titled Sexual Assault, dated 5/20/25, reflected all staff were educated on recognizing and reporting any signs of sexual abuse and inappropriate sexual behaviors.

Record review of documents provided by the Regional Nurse Consultant titled Abuse, Neglect, and Exploitation-Pre/Post Test dated 5/20/25, reflected the DON tested all staff over their knowledge on recognizing and reporting abuse, neglect, and exploitation.

Record review of a progress note, dated 5/20/25 at 11:25 AM, reflected Resident #1 was connected to psychiatric services to address sexual behaviors.

Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Pla Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in neglect.

Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part

the following:

Policy Statement:

Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

As part of the resident abuse prevention, the administration will:

.

3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.

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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

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)

F 0607 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 Level of Harm - Immediate more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the jeopardy to resident health or effectiveness of the corrective systems that were put into place. safety

Residents Affected - Some

Note: The nursing home is disputing this citation.

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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

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)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45054

Residents Affected - Few Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and Note: The nursing home is misappropriation of resident property, were reported immediately, but no later than 2 hours after the disputing this citation. allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including to the State Agency in accordance with State law through established procedures, for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation .

1. The facility failed to report to the state agency when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others.

2. The facility failed to report to a law enforcement entity and the state agency when Resident #2 obtained and used nonprescription drugs at the facility, was found exhibiting signs of an overdose, and was transported to the local hospital where he tested positive for marijuana.

These failures could place residents at risk for continued abuse due to unreported allegations of abuse.

Findings include:

1. Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE REDACTED]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion), COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure).

Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors.

Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.

Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following:

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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

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)

F 0609 HPI:

Level of Harm - Minimal harm or LTC on therapy potential for actual harm Today: Residents Affected - Few . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff Note: The nursing home is and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer disputing this citation. safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors.

Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following:

[SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt.

Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following:

[DON] was notified by [Activity Director] that [Resident #1] has inappropriately touched a student that was in facility for a activity . [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware .

Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following:

[Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1] so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities.

Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time.

Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents.

Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following:

-Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25.

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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

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)

F 0609 Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services. Level of Harm - Minimal harm or potential for actual harm Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. Residents Affected - Few

In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident Note: The nursing home is #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not disputing this citation. have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during

this interview.

In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who

she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1.

In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated

she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long.

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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

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)

F 0609 In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor Level of Harm - Minimal harm or was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her potential for actual harm the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Residents Affected - Few Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however,

they were unable to find placement and Resident #1's RP stated she could not care for the resident. The Note: The nursing home is DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did disputing this citation. not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw

the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation or report it to the state agency. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed.

In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to

the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home.

In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON .

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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

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)

F 0609 2. Record review of Resident 2's face sheet, dated 5/16/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE REDACTED]. Resident # 2 had diagnoses which included: COPD (lung disease), Level of Harm - Minimal harm or multiple sclerosis (nerve disorder), bipolar disorder (mood disorder), and legal blindness. potential for actual harm

Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 5/02/25, reflected he Residents Affected - Few had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most Note: The nursing home is ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication disputing this citation. under the high-risk drug class that included an antidepressant, diuretic, and anticonvulsant.

Record review of Resident #2's care plan, dated 2/20/25, did not reflect a care plan for the resident's behavior related to substance abuse.

Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD, reflected the following:

[Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents.

Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following:

[Resident #2] 30-day discharge notice was issued and signed due to lack of facility compliance.

Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD, reflected the following:

[SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help

him look for housing.

Record review of Resident #2's progress notes on 2/15/25 at 8:00 AM by LVN A, reflected the following:

[LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware.

Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following:

Today's Visit (continued)

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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

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)

F 0609 Reason for Visit: Drug / Alcohol Assessment

Level of Harm - Minimal harm or Diagnosis: Bladder infection potential for actual harm . Residents Affected - Few Labs: Note: The nursing home is disputing this citation. Marijuana (Cannabinoid)- Positive

.

Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD, reflected the following:

[SSD] reached out to [Resident #2's] [PO] to inform her of his resent [sic] drug overdose hospital visit.

Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following:

-Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25.

-Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25.

-Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain.

Further review of this document reflected Resident #2 did not have an order for medical marijuana.

Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility.

He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem.

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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

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)

F 0609 In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about Level of Harm - Minimal harm or a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, potential for actual harm and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there Residents Affected - Few was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not Note: The nursing home is accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 disputing this citation. used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to

the facility. He could not state why he did not investigate or report these incidents.

In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in

the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in

the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else.

She stated she would not order THC to the facility again.

In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go.

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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

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)

F 0609 Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug Level of Harm - Minimal harm or screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing potential for actual harm order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated Residents Affected - Few staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO Note: The nursing home is informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator disputing this citation. stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm .

Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part

the following:

Policy Statement:

Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

.15. Investigate and report any allegations of abuse within timeframes as required by federal requirements

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45054 potential for actual harm Based on observation, interview and record review the facility failed to ensure in response to allegations of Residents Affected - Few abuse, neglect, exploitation or mistreatment have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation Note: The nursing home is was in progress for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and disputing this citation. exploitation.

1. The facility failed to investigate an alleged violation when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others.

2. The facility failed to investigate when Resident #2 obtained and used nonprescription drugs at the facility, was found exhibiting signs of an overdose, and was transported to the local hospital where he tested positive for marijuana .

This failure could place all residents at an increased risk for abuse and neglect.

Findings included:

1.

Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE REDACTED] with diagnoses that included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure).

Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors.

Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.

Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following:

HPI:

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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

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)

F 0610 LTC on therapy

Level of Harm - Minimal harm or Today: potential for actual harm . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff Residents Affected - Few and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be Note: The nursing home is more appropriate to reside in a male only locked unit given behaviors. disputing this citation. .

Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following:

[SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt.

Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following:

[DON] was notified by [Activity Director] that [Resident #1] has inappropriately touched a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware.

Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following:

[Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities.

Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time.

Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents.

Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following:

-Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0610 Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services. Level of Harm - Minimal harm or potential for actual harm Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. Residents Affected - Few

In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident Note: The nursing home is #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not disputing this citation. have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during

this interview.

In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who

she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1.

In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated

she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long.

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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

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)

F 0610 In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor Level of Harm - Minimal harm or was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her potential for actual harm the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Residents Affected - Few Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however,

they were unable to find placement and Resident #1's RP stated she could not care for the resident. The Note: The nursing home is DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did disputing this citation. not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw

the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation or report it to the state agency. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed.

In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to

the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home.

In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON .

2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0610 Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE REDACTED] with diagnoses that included: COPD (lung disease), multiple sclerosis Level of Harm - Minimal harm or (nerve disorder), bipolar disorder (mood disorder), and legal blindness. potential for actual harm

Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 5/02/25, reflected he Residents Affected - Few had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most Note: The nursing home is ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication disputing this citation. under the high-risk drug class that included an antidepressant, diuretic, and anticonvulsant.

Record review of Resident #2's care plan, dated 2/20/25, did not reflect a care plan for the resident's behavior related to substance abuse.

Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD reflected the following:

[Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents.

Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following:

[Resident #2] 30 day discharge notice was issued and signed due to lack of facility compliance.

Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD reflected the following:

[SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help

him look for housing.

Record review of Resident #2's progress notes, dated 2/15/25 at 8:00 AM by LVN A reflected the following:

[LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware.

Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following:

Today's Visit (continued)

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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

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)

F 0610 Reason for Visit: Drug / Alcohol Assessment

Level of Harm - Minimal harm or Diagnosis: Bladder infection potential for actual harm . Residents Affected - Few Labs: Note: The nursing home is disputing this citation. Marijuana (Cannabinoid)- Positive

.

Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD reflected the following:

[SSD] reached out to [Resident #2's] [PO] to inform her of his resent drug overdose hospital visit.

Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following:

-Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25.

-Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25.

-Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain.

Further review of this document reflected Resident #2 did not have an order for medical marijuana.

Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility.

He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem.

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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

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)

F 0610 In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about Level of Harm - Minimal harm or a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, potential for actual harm and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there Residents Affected - Few was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not Note: The nursing home is accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 disputing this citation. used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to

the facility. He could not state why he did not investigate or report these incidents.

In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in

the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in

the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else.

She stated she would not order THC to the facility again.

In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0610 Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug Level of Harm - Minimal harm or screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing potential for actual harm order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated Residents Affected - Few staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO Note: The nursing home is informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator disputing this citation. stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm .

Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part

the following:

Policy Statement:

Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

.15. Investigate and report any allegations of abuse within timeframes as required by federal requirements

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45054

Residents Affected - Some Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included Note: The nursing home is measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial disputing this citation. needs that were identified in the comprehensive assessment for two of six residents (Resident #1 and Resident #2) reviewed for care plans.

1. The facility failed to identify Resident #1 had physical and/or verbal behaviors on his Admission MDS assessment dated [DATE REDACTED] or develop a care plan to address the behavior.

2. The facility failed to develop a care plan to address Resident #2's substance abuse .

This failure could place residents at risk of not receiving appropriate care and services.

Findings include:

1.

Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE REDACTED]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure).

Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors.

Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0656 In an interview on 5/20/25 at 11:20 AM, the DON stated the MDS Nurse was ultimately responsible for updating care plans after every care plan conference and as needed if there were any significant changes. Level of Harm - Minimal harm or The DON stated she assisted with creating and updating care plans. The DON stated she was aware of potential for actual harm Resident #2's history of drug use and the incident that occurred on 2/15/25 when he was transported to the ER after exhibiting signs of drug use. She stated she did not know why Resident #2 was not care planned for Residents Affected - Some his behavior regarding drug use; however, he should have been. She stated it was important to keep care plans updated to include any new incidents and changes in condition so staff would be aware of all the Note: The nursing home is resident's care needs and interventions in place. disputing this citation.

In an interview on 5/20/25 at 12:24 PM, the MDS Nurse stated some of his responsibilities included timely completion of MDS Assessments and to ensure triggers on corresponding MDS had a care plan to address it. The MDS Nurse stated he updated care plans during comprehensive MDS Assessments and when there were any changes in the residents' condition; however, updating the care plans were the responsibility of the entire IDT. The MDS Nurse stated not updating care plans could place the residents at risk of not getting their care needs met by the facility .

2.

Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE REDACTED]. Resident #2 had diagnoses which included: COPD (lung disease), multiple sclerosis (nerve disorder), bipolar disorder (mood disorder) and legal blindness.

Record review of Resident #2's Quarterly MDS Assessment, dated 5/02/25, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication under the high-risk drug class that included an antidepressant, diuretic and anticonvulsant.

Record review of Resident #2's care plan, dated 2/20/25 , did not reflect a care plan for the resident's behavior related to substance abuse.

Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD, reflected the following:

[Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents.

Record review of Resident #2's progress notes on 2/15/25 at 8:00 AM by LVN A, reflected the following:

[LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0656 In an observation and interview on 5/19/25 at 9:14 AM, Resident #2 was well-groomed, alert and oriented, and showed no s/sx of drug use or intoxication. Resident #2 stated he ended up at the local hospital on Level of Harm - Minimal harm or 2/15/25 due to his stupid ways of using drugs. Resident #2 admitted to using marijuana. Resident #2 stated potential for actual harm he had a long history of heavy drug use but stopped and had only been using marijuana sometimes. Resident #2 stated he had been clean since, because his PO found out about the incident, and it risked him Residents Affected - Some going back to prison and it caused the MD to take him off his pain medication temporarily. Resident #2 stated residents were always bringing drugs into the facility, but he did not state who. He stated the staff were also Note: The nursing home is aware that drugs were being brought into the facility . disputing this citation.

In an interview on 5/20/25 at 11:20 AM, the DON stated the MDS Nurse was ultimately responsible for updating care plans after every care plan conference and as needed if there were any significant changes.

The DON stated she assisted with creating and updating care plans. The DON stated she was aware of Resident #2's history of drug use and the incident that occurred on 2/15/25 when he was transported to the ER after exhibiting signs of drug use. She stated she did not know why Resident #2 was not care planned for his behavior regarding drug use; however, he should have been. She stated it was important to keep care plans updated to include any new incidents and changes in condition so staff would be aware of all the resident's care needs and interventions in place.

In an interview on 5/20/25 at 12:24 PM, the MDS Nurse stated some of his responsibilities included timely completion of MDS Assessments and to ensure triggers on corresponding MDS had a care plan to address it. The MDS Nurse stated he updated care plans during comprehensive MDS Assessments and when there were any changes in the residents' condition; however, updating the care plans were the responsibility of the entire IDT. The MDS Nurse stated not updating care plans could place the residents at risk of not getting their care needs met by the facility .

Record review of the facility's policy titled, Resident Assessments revised on 11/2019, reflected in part the following:

Policy Statement: A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements.

Policy Interpretation and Implementation:

1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements:

a. OBRA required assessments - conducted for all residents in the facility:

(1) Initial Assessment (Comprehensive) - Conducted within fourteen (14) days of the resident's admission to

the facility

.

(3) Significant Change in Status Assessment (Comprehensive) - Conducted when there has been a significant change in the resident's condition.

2. A 'comprehensive assessment' includes:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0656 a. Completion of the Minimum Data Set (MDS);

Level of Harm - Minimal harm or b. Completion of the Care Area Assessment (CAA) Process; and potential for actual harm c. Development of the comprehensive care plan. Residents Affected - Some 3. A Significant Change in Status Assessment (SCSA) is completed within 14 days of the interdisciplinary Note: The nursing home is team determining that the resident meets the guidelines for major improvement or decline disputing this citation. .

5. A SCSA is required when a resident

.

d

.

(9) Emergence of a condition/disease in which a resident is judged to be unstable.

Record review of the CMS's RAI Version 3.0 Manual dated October 2024, reflected in part the following:

Section E-Behaviors

E0200: Behavioral Symptom-Presence & Frequency

Note presence of symptoms and their frequency-

Coding:

0. Behavior not exhibited

1. Behavior of this type occurred 1 to 3 days

2. Behavior of this type occurred 4 to 6 days, but less than daily

3. Behavior of this type occurred daily

A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)

B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)

C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing,

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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

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)

F 0656 rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, Level of Harm - Minimal harm or potential for actual harm disruptive sounds) .

Residents Affected - Some

Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45054 safety Based on observation, interview and record review the facility failed to ensure that each resident received Residents Affected - Some adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #2) reviewed for accidents. Note: The nursing home is disputing this citation. -The facility failed to ensure Resident #2 was provided with adequate supervision to prevent the resident from using nonprescription drugs at the facility. On 2/15/25 Resident #2 was found exhibiting signs of an overdose and was transported to the local hospital where he tested positive for marijuana.

An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with a 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.

This failure could place residents at risk for accidents that could lead to serious injury or harm.

Findings include:

Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE REDACTED]. Resident #2 had diagnoses which included: COPD (lung disease), multiple sclerosis (nerve disorder), bipolar disorder (mood disorder) and legal blindness.

Record review of Resident #2's Quarterly MDS assessment, dated 5/02/25, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication under the high-risk drug class which included an antidepressant, diuretic, and anticonvulsant.

Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD, reflected the following:

[Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents.

Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following:

[Resident #2] 30-day discharge notice was issued and signed due to lack of facility compliance.

Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD reflected the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0689 [SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help

Level of Harm - Immediate him look for housing. jeopardy to resident health or safety Record review of Resident #2's progress notes, dated 2/15/25 at 8:00 AM by LVN A, reflected the following:

Residents Affected - Some [LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of Note: The nursing home is limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the disputing this citation. side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware.

Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following:

Today's Visit (continued)

Reason for Visit: Drug / Alcohol Assessment

Diagnosis: Bladder infection

.

Labs:

Marijuana (Cannabinoid)- Positive

.

Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD, reflected the following:

[SSD] reached out to [Resident #2's] [PO] to inform her of his resent [sic] drug overdose hospital visit.

Record review of Resident #2's care plan, dated 2/20/25 , did not reflect a care plan for the resident's behavior related to substance abuse.

Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following:

-Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0689 -Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25. Level of Harm - Immediate jeopardy to resident health or -Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain. safety Further review of this document reflected Resident #2 did not have an order for medical marijuana. Residents Affected - Some

Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility. Note: The nursing home is He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to disputing this citation. other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem.

In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about

a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to

the facility. He could not state why he did not investigate or report these incidents.

In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in

the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in

the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else.

She stated she would not order THC to the facility again.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0689 In an interview on 5/16/25 at 2:09 PM, the SSD stated to her knowledge, the DON addressed the drug issue that was brought to their attention by other residents. The SSD stated there were residents in the facility who Level of Harm - Immediate were on parole and must complete drug screenings. She stated Resident #2 was on parole for a sex offense jeopardy to resident health or and drug use. The SSD stated the parole officers informed the facility of any failed drug screenings. The safety SSD stated Resident #2 failed a drug screening on 2/11/25 and his PO was informed he would be discharged from the facility for bringing drugs into the facility. She stated Resident #2 had already failed a Residents Affected - Some drug screening that was positive for marijuana on 2/06/25. The SSD stated the facility was trying to find a facility for Resident #2 to transfer to, but it was difficult due to his background. Note: The nursing home is disputing this citation. In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go.

Attempted interview on 5/16/25 at 4:32 PM with LVN A, who worked with Resident #2 when he was sent out to the hospital on 2/15/25, was unsuccessful due to no response to call. Callback information was left on the voicemail.

In an observation and interview on 5/19/25 at 9:14 AM, Resident #2 was well-groomed, alert and oriented, and showed no s/sx of drug use or intoxication. Resident #2 stated he ended up at the local hospital on 2/15/25 due to his stupid ways of using drugs. Resident #2 admitted to using marijuana. Resident #2 stated

he had a long history of heavy drug use but stopped and had only been using marijuana sometimes. Resident #2 stated he had been clean since because his PO found out about the incident, and it risked him going back to prison and it caused the MD to take him off his pain medication temporarily. Resident #2 stated residents were always bringing drugs into the facility, but he did not state who. He stated the staff were also aware drugs were being brought into the facility.

Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm .

Record review of the facility's, undated, policy titled Illegal Drug Use, reflected in part the following:

Policy:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0689 This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession or distribution of any substance which is unlawful under the Controlled Substances Act. Level of Harm - Immediate jeopardy to resident health or This facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and safety terminate staff employment for violation of this policy. Residents Affected - Some Policy Explanation and Compliance Guidelines: Note: The nursing home is disputing this citation. 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the

premises of this facility.

2. No one is allowed to sell, buy, transfer, distribute or use said illegal drugs on the premises of this

facility.

3. No one is allowed to sell, buy, transfer, distribute or use any drug paraphernalia on the premises of this facility.

4. Anyone that is under a physician's care and requires the use of prescription or over-the-counter drugs must follow these rules:

a. Use prescription drugs only if a licensed health care provider has prescribed them within the last year.

b. Directions must be followed as written by the physician.

c. Prescribed drugs must be in the original container.

5. The facility reserves the right to consult with said physician if prescription or over-the counter drugs create risk.

6. All facility staff that enter the facility may be subject to an investigation of substance abuse to

include tests that detect the use of alcohol or any substance which is unlawful under the Controlled Substance Act .

This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 05/19/25 at 3:25 PM

The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM:

[Nursing Facility]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 50 455881 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0689

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.

1. 1. 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 REDACTED]. Drug test was negative.

2. 2. All residents have the potential to be affected although no other residents have been affected.
3. 3. 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

4. 4. 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.

5. 5. Resident is still being discharged pending acceptance.
6. 6. The DON/designee will monitor the effectiveness of assessments completed of residents .
7. 7. QAPI meeting will be held monthly, and findings will be discussed.
8. 8. A pre/posttest will be completed by staff on signs/symptoms of drug use Completion 5/20/2025 and

ongoing.

9. 9. 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.

Monitoring of the POR included the following:

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/20/2025 Dfw Nursing & Rehab 900 W Leuda St Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Note: The nursing home is disputing this citation.

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 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/20/2025 Dfw Nursing & Rehab 900 W Leuda St Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Note: The nursing home is disputing this citation.

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