Dfw Nursing & Rehab

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

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

looking for a safe discharge location; he reports he had to contact local police and had to have them come out twice before the police would take Resident #3 to the local hospital for evaluation and remove him from

the property. The Administrator stated that he felt Resident #2 did not remember the altercation, however, a few hours later she was able to call a family member and give details.Confidential interview with family member #1 revealed Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The resident was confused and the family member was frustrated and concerned for Resident #2's safety in the facility. Family member #1 stated they were focused on finding a suitable facility for the resident to relocate to.Review of facility policy Abuse Prevention Program, revised December 2016, revealed 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 revealed as part of the resident abuse prevention, the administration will:l. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, otherresidents, 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, ormistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification andreporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of facility policy Resident Rights, revised December 2016 revealed; Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to;C. be free from abuse, neglect, misappropriation of property, and exploitation. A past Immediate Jeopardy (IJ) was found on 08/17/25 and the immediacy was removed on 10/05/25. While the IJ was removed on 10/025/25, the facility remained out of compliance at a severity of actual harm due to the facility's need to monitor the effectiveness of their corrective systems.

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

10/14/2025

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

as an independent and neutral intermediary to help resolve complaints and disputes fairly between individuals and an organization or government agency) and left a message concerning Resident #1's immediate discharge. SW did not document that a message was left on Ombudsman's voicemail and could not provide a date when she left the message. SW could not provide a copy of the first 30-day notice that was given to Resident #1 and could not provide the date. SW provided a copy of the immediate discharge notice given to Resident #1. Record review of an email conversation with the Ombudsman on 10/14/2025 at 4:33 p.m. revealed she did not receive a phone call or email r/t a notification before or after Resident #1's discharge on [DATE REDACTED]. On 10/14/2025 at 4:17 p.m., an interview with DON revealed that Resident #1 exhibited behaviors that placed residents' and staff's safety at risk. He was non-compliant with facility smoking rules, would go out to the laundry, take staff's food from the employee breakroom, and verbally threaten to harm the employees. Resident #1 threatened to kill other staff and himself. Resident #1's family member was informed of his behavior, but she thought the staff were not telling the truth. The family member was verbally aggressive towards staff when she was informed by phone of Resident #1's behaviors. DON stated she was not aware the Ombudsman was not notified of Resident #1's discharge. On 10/14/2025 at 4:55 p.m., an interview with the ADM revealed that Resident #1 had to be given an immediate discharge for the safety of the other residents and staff. Resident #1 was non-compliant with the smoking rules and verbally aggressive towards other residents and staff. Resident #1 was discharged to the hospital for a psychiatric evaluation and SW planned for transfer to a group home. Resident #1's family member came into the facility to pick up his belongings and began cursing staff. The ADM was not aware that the Ombudsman had not been notified by SW r/t Resident #1's immediate discharge. The ADM expectations are for the SW to contact the Ombudsman concerning all discharges from the building and document in SS notes of notification.Record review of the facility's admission and Discharge including AMA, Against Medical Advice Policy dated March 2017, reflected, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.

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

10/14/2025

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 0740 Level of Harm - Actual harm Residents Affected - Few

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

effects from incidents of assault as Resident #2 has no real short-term memory from the dementia and that when EMT came in to assess she acted like she did not know what happened but was able to tell her family member in detail a few hours later when Resident #2 called her. The SW stated that the facility has conducted trauma assessments with Resident #2 but no further actions had been taken with that information. When asked about referral for psychological assessment or therapy due to the positive responses on the trauma assessments, the SW responded that she had not made any referrals as Resident #2 was known to refuse services in the past such as dental and vision however family were able to easily get Resident #2 to participate with care from outside providers. SW stated that she had not noticed any change in Resident #2's behaviors since Resident #3 was discharged .Interview on 10/14/2025 at 4:26 PM with the DON revealed that psychology services were offered in facility multiple times a week, however due to Resident #2's advanced dementia they had not referred for an evaluation or services. The DON stated that the SW has done trauma screenings, but no referrals were sent as Resident #2 was difficult to assess. The DON stated that Resident #2 was placed on 1:1 with a staff member so that someone was always with her. The DON indicated that even though Resident #2 may have been targeted by Resident #3,

they wanted to keep eye on her for her safety since she has had history of taking things from other residents however has not seen or heard of any negative response from Resident #2 with having the 1:1 monitoring by staff. The DON stated that staff had been informed if Resident #2 asked why she was being followed around they were to inform her it was to keep her company. Interview on 10/14/2025 at 5:05PM with the Administrator revealed he had been employed at the facility since 9/10/2025. The Administrator stated that he felt Resident #2 did not remember the altercation on 10/03/2025, however, a few hours later

she was able to call her family member and give details. The Administrator stated he would expect behavioral health services to be offered to residents after they were assaulted by another resident and for staff to follow what was recommended by the mental health providers as they are in the building on Wednesdays every week. The Administrator stated he also expected staff to call on these contracted mental health providers as needed, to alert them to situations that had happened in the facility since their last visit, and to do what was needed or recommended by those providers. Confidential interview with family member #1 revealed Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The resident was confused and the family member was frustrated and concerned for Resident #2's safety in the facility. Family member #1 stated they were focused on finding a suitable facility for the resident to relocate to. Resident #2 did not receive any behavioral services after each incident and Resident #3 continued to abuse Resident #2.Review of facility policy Unmanageable Residents, revised April 2010 revealed; Each resident will be provided I. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately:a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.);b. Notify the resident's Attending Physician for instructions; Review of facility policy Resident Rights, revised December 2016 revealed; Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;f. communication with and access to people and services, both inside and outside the facility;h. be supported by the facility in exercising his or her rights;

Event ID:

Facility ID:

If continuation sheet