Inspection·April 23, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the facility did not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion for 2 of 3 residents (Resident #1 and #2) reviewed for abuse, neglect, and or exploitation. for 2 of 3 residents reviewed for abuse. (Resident #1 and Resident #2) 1. The facility failed ensure Resident #1 and #2's were free from resident-to-resident abuse, which occurred on 04/05/25. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of an undated admission Record revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of Encephalopathy (broad term for any brain disease that alters brain function or structure), Bipolar Disorder and Unspecified Dementia, Unspecified Severity, with Agitation. Record review of Optional State Assessment Minimum Data Set, dated [DATE] revealed Resident #1 had a BIMS score of 11, which indicated mild cognitive deficit. Behavioral Symptoms reflected: Physical behavioral symptoms directed towards others, 0 Behavior not exhibited. Record review of a care plan dated 03/13/2025 revealed; Focus: Resident #1 had a history of being physically aggressive with staff. Interventions/Tasks: On 10/12/2024 Resident #1 hit a staff member who was attempting to make the bed in the room so she could get a roommate. Record review of an undated admission Record revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, Unspecified Severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Optional State Assessment Minimum Data Set, dated [DATE] revealed; Resident #2 has a BIMS score of 11, which indicated mild cognitive deficit. Behavioral Symptoms reflected: Physical behavioral symptoms directed towards others, 0 Behavior not exhibited. Record review of care plan dated 04/11/2025 revealed; Focus: Resident #2 has a male companion in the facility and both have expressed the desire to have a sexual relationship. Interventions/Tasks: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 455881 Printed: 05/15/2026 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 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)