Dfw Nursing & Rehab

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bad, and the Administrative staff should have taken him more seriously before this. An interview on 09/07/25 at 4:58 PM with the Hospital SANE revealed she had just seen Resident #2, and examined her for possible sexual assault. She said the resident could not remember what happened or answer any questions about it, so the information she got came mostly from her family. She said she did a full head-to-toe assessment, taking pictures of anything she found, and swabbed her for DNA. She said the only injury she found was some redness on her face , which her family said was not normal for her, but that lack of injury did not necessarily mean lack of assault. She said Resident #2 did not remember at all what happened, and did not seem particularly upset. An interview on 09/07/25 at 6:38 PM with RN A revealed Resident #1 was trying to go into a man's room on the night of 09/06/25, and he and the other nurse (LVN C) told him to stop trying to go into rooms because it was late and people wanted to rest. He said he was aware of Resident #1 and another resident who had recently been discharged having a consensual sexual relationship, and he had reported it to the DON and Administrator. He said both residents were fully alert and oriented and able to consent. He said he was not aware of Resident #1 trying to have sex with any other resident. He said they were near the nurses station at the front door (at the opposite of a hall from Resident #1 and Resident #2's rooms) at the time, and watched Resident #1 go all the way down the hall, and into his room. He said it was about 4:00 AM on 09/07/25 when that happened. He said around 4:45 AM Resident #2 was in bed, with the light on, which was normal for her. He said at that time, Resident #1 was

in his room, sitting in his wheelchair, watching TV. He said Resident #2 had never had any sexual behaviors, or shown any interest in drugs, that he was aware of. He said they had done training on abuse and neglect, including sexual abuse, and what consent meant, and he did not know if Resident #2 would be able to give consent, but Resident #1 was able to consent. He said Resident #2 could remember bits and pieces of things that happened years ago, but was not able to remember recent things because her short-term memory was very poor. He said he did not think someone with poor short-term memory would be able to give informed consent, which meant a person was able to understand the implications of their decisions. An interview on 09/07/25 at 7:03 PM with LVN C revealed he was working at the station by the front door, on admitting a resident, when he heard the call on the intercom that there was a missing resident, so he went to the other nurses station. He said he checked in Resident #2's room, and she was not there so he went room to room and found Res[TRUNCATED]

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

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

part of the resident abuse prevention, the administration will: (.) 7. (.) and report any allegations of abuse within timeframes as required by federal requirements;(.)

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

He said he thought the staff talked to residents about consent and safe sex. A telephone interview on 09/09/25 at 9:43 AM with Resident #3 revealed she denied having any relationship with Resident #1, and when asked about the staff witnessing them having sexual contact, she said the staff were lying. When asked if the staff talked to them about consent and safe sex, she said they did not, because they were not having sex. An interview on 09/09/25 at 1:17 PM with the ADON revealed she was aware of some of the residents having sexual relations with each other. She said aside from Resident #1 and Resident #3, they had Residents #9 and #10 who had originally asked to be in a room together, but at some time were moved to separate rooms, but she did not know if they requested that, or it was some other reason. She said Resident #11 actually brought Resident #12 from another facility because she was his girlfriend, and they used to room together, and are still a couple, though they do not room together any more. She said Resident #7 and Resident #8 were a recent couple. She said she heard about it from staff who told her they go out on dates, and sometimes come back drunk. She said Residents #7 and #8 were signing out once for overnight, and she asked when they expected to return, and Resident #8 said in the morning, when the room they had arranged closed. She told them she did not feel it was a good idea for them to be gone overnight, because of his health condition, but he just asked What are you going to do when we get married? She notified his responsible party, and the responsible party said she hoped they did get married so they could take her name off the contact list. She did not know of any official assessment, but she thought the management team was aware of all of the relationships. She thought there were probably care plans in place for them, but she was not sure. An interview on 09/09/25 at 2:45 PM with the MDS Coordinator revealed he had been told to do acute careplans about resident relationships, but it had been a long time ago. He said the ADON and DON did most of the acute careplans about things like sexual activity.

He said that even though he had not done careplans for all of them, he had been requested to do a quick BIMS assessment on residents before, as part of an assessment of them to decide if they were competent to make the decision to be in a sexual relationship. An interview on 09/09/25 at 4:01 PM with the DON revealed she had done careplans on residents for relationships before. She said the careplans for relationships, if she knew about them, would probably fall to her, and the Social Worker could also do them, but she never thought to care plan the couples having sex. She said she would have to take a look at the individual careplans, and that the careplans were important because the staff would know how to care for residents, and what the interventions were for helping them reach their goals. Review of the policy Care Planning - Interdisciplinary Team, revised September 2013, reflected Policy StatementOur facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team (.) 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. (.) The policy did not directly address acute careplans for issues not covered by the resident's comprehensive assessment.

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