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Complaint Investigation

Dfw Nursing & Rehab

September 10, 2025 · Fort Worth, TX · 900 W Leuda St
Citations 3
CMS Rating 1/5
Beds 98
Provider ID 455881
Healthcare Facility
Dfw Nursing & Rehab
Fort Worth, TX  ·  View full profile →
Inspection Summary

DFW Nursing & Rehab in Fort Worth, TX — inspection on September 10, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

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]

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Dfw Nursing & Rehab

900 W Leuda St Fort Worth, TX 76104

SUMMARY STATEMENT OF DEFICIENCIES

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Dfw Nursing & Rehab

900 W Leuda St Fort Worth, TX 76104

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Fort Worth, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DFW Nursing & Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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