Dfw Nursing & Rehab

F 0600 Level of Harm - Actual harm Residents Affected - Few

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

stated that's when she told Resident #1 to go into the building because her nose was bleeding. LVN C stated Resident #1 then stated, look what he (F word) did, LVN C stated she told Resident #1 that Resident #2 did not do that, and she was hit in the nose due to recoil on the cane when she grabbed it. LVN C stated Resident #2 was still outside sitting down and his back was turned, and Resident #1 went back outside and swiped Resident # 2 on his head. LVN C stated that's when Resident #2 hit her with the cane causing Resident #1 to stumble off. LVN C stated that she was trying to calm Resident #2 down because he was shaking. LVN C stated she told LVN D that he needed to do something because Resident #1 was really looking for a fight with Resident #2. In an interview on 11/20/25 at 5:11 PM, DON stated she was not at the facility during the day Residents #1 and #2 got into a fight due to it happening on the weekend. The DON stated that she was told the recoil on the cane hit in the eye. The DON stated that LVN D said he took the cane. The DON stated that Resident #1 was taken to [Hospital Name] and Resident #2 was taken to jail.

The DON stated Resident #1 had to get stitches above her eye. The DON stated Resident #1 was placed 1

on 1 with a caregiver until she was discharged from the facility. The DON stated that all the fighting couldn't be tolerated. The DON stated Resident #2 was referred for psych services, and Resident #2 was taken to jail. The DON stated they reeducated staff on resident-to-resident altercations and being proactive in separating residents. The DON stated that she expects staff to intervene, deescalate, separate the residents, report the incident, assess the residents, make sure all residents are safe, and do not argue with

the residents. She stated the risk is that a resident could end up hurt or injured. In an interview on 11/20/25 at 6:36 PM, The ADM stated staff are expected to separate the residents as soon as possible, de-escalate

the situation, and report to him and the DON. The ADM stated he encourages the staff to find out what's going on and try and solve the situation. The ADM stated it's a lot of situations he has de-escalated just by talking to the residents. The ADM stated the risk of residents getting into a fight is that someone can get hurt or staff could get hurt, or medical emergencies could happen that's why it's important to break it up as soon as you can. Record Review of the facility's Abuse Policy in part indicated - All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation -2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.3.

Immediately is defined as a. within two hours of an allegation involving abuse or result in serious bodily injury.

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

11/20/2025

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

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

presented a progress note from the incident and stated that's all she could find from the investigation.

Resident #4 was unable to be interviewed due to being in the hospital at the time of the visit. In an interview

on 11/20/25 at 11:46 AM, Med Tech F stated Resident #4 was given a shower and Resident #4 seemed agitated already and the aid that assisted Resident #4 could not get her dressed in the showers, so the aid brought her back to the resident's room to get her dressed. Med Tech F stated she couldn't remember the name of the aid that was assisting Resident #4 at the time. Med Tech F stated when the aid went to try and get Resident #4 dressed Resident #4 laid down on the floor and kept stating she did not want to get dressed and she just wanted to go to [Hospital Name 2]. Med Tech F stated [Hospital Name 2] is Resident #4's hospital of choice whenever she wants to be sent out to the hospital. Med Tech F stated Resident #4 did not fall and she willingly got on the floor. Med Tech F stated Resident #4 was not injured at all. Med Tech F stated Resident #4 always gets on the floor when she doesn't get her way. In an interview on 11/20/25 at 5:11 PM, the DON stated she could not find the PIR for intake 1034343. The DON stated the previous administrator would have had the missing PIR due to the incident happening when he was the active administrator, the DON stated that they couldn't find any information the old administrator had but she does remember what happened. The DON stated that during the incident with Resident #4 that the resident got

on the floor while she was naked and kept saying she wanted to go to the hospital. The DON stated that

they couldn't pick the resident up off the floor and the resident wouldn't get up by herself, and they couldn't drag her, so they called 911 to pick up the resident. The DON stated that Resident #4 was not hit by any of

the staff. The DON stated that they are expected to keep all PIR's to have them for future references. She stated the risk of not having the PIR's can cause investigations to not be thoroughly done, poor patient care, and fines. In an interview on 11/20/25 at 6:36 PM, the ADM stated that the old administrator was disgruntled when he was fired. The ADM stated that the old administrator told him that he was going to make sure he gave him all the paperwork from the previous incidents, but he didn't leave any paperwork at all. The ADM stated that typically it's the administrator's job to keep up with PIR's. The ADM stated that due to him not being the administrator at the time of the incident and with no PIR to reference he can't speak about what happened during the incident. The ADM stated the risk of not having the PIR's is that the facility can be fined for not having that information for surveyors to reference. Record Review of the facility's Abuse Policy in part indicated - All reports of resident abuse (including injuries of unknown origin).are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation -2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.Investigating Allegations- 1. All allegations are thoroughly investigated. The administrator initiates investigations.Follow-Up Report 1. Within 5 business days of the incident, the administrator will provide a follow-up investigation report.2. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if

the allegation was verified. The follow-up investigation report will provide as much information as possible at

the time of submission of the report.

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

11/20/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

mean they can't sign themselves out. The ADM stated they assess the residents and decide by their Wander assessments. The ADM stated when residents are admitted he expects staff to transfer all information from medical records into the system right away that day, he said he was unsure of the timeframe in which that information should be transcribed. The ADM stated they shouldn't be waiting 2-3 days to put in admitting diagnoses information he said because they need to know how to be properly care planned. The ADM stated that he fired the social worker they had because she wasn't putting in important information in the system and he has since then been looking to hire a new social worker. The ADM stated

the risk of not accurately transcribing records into the database is that it could cause staff to miss something important. Record Review of the facility's Charting and Documentation Policy indicated in partAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding

the resident's condition and response to care. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

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

11/20/2025

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)