Health 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: Page 1 of 3 455881 455881 04/23/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2 will notify staff and schedule time for private physical contact. Resident #2's roommate will be asked if she was willing to leave the room during those times. Record review of the Provider Investigation Report dated 04/05/2025 revealed, these two residents were roommates and as one resident was coming out of the bathroom, the other resident was trying to go in. The residents stated that words were exchanged and then the residents grabbed each other on the arms and hands and tried to push their way past each other. The residents resolved the issue themselves and did not say anything to anyone until two days later. Once the Administrator was notified, the residents were separated and moved to different rooms and report was made. Record review of the electronic medical record revealed no skin assessments for Resident #1 or #2. Review of Incident and Accident Report for March 2025, revealed Resident #2 had the following incidents: 03/15/25 verbal altercation with another resident 03/29/25 physical aggression (report did not mention if it was towards another resident or staff member). Observation and interview on 04/23/2025 at 11:57 a.m. with Resident #1 revealed on an unknown date (unable to recall the day and time of incident) she was in the shared restroom when Resident #2 knocked on the door and told Resident #1 to get out; I will knock your ass out. Resident #1 stated that she attempted to move past Resident #2 who was standing in the doorway of the restroom. Then Resident #2 grabbed Resident #1's arm and wrist. Resident #1 stated Resident #2 released the hold and Resident #1 was able to walk out of the restroom. Resident #1 stated Resident #3 came into the room and then notified LVN A. LVN A notified local police. Resident #1's skin did not have any visible signs of bruising on the hands or forearms. Interview on 04/23/2025 at 12:04 p.m. revealed, Resident #3 stated she heard Resident #1 hollering for help in her room so she went to Resident #1's room . Resident #3 stated, they (Residents #1 and #2) were fighting. Resident #3 did not recall the exact date. She stated she witnessed Resident #2 grab Resident #1's arm and Resident #2 called Resident #1 a bitch. Resident #3 stated she then went to get the nurse. She stated that LVN A called the police and she gave a witness statement to the police. She stated the problem was the roommates were a bad match up because one was older than the other and the younger roommate went in and out of the room and had a boyfriend. That was the worst thing they did at the facility was not match people for roommates. Interview on 04/23/2025 at 1:00 p.m. with Resident #2 revealed she was not used to having a roommate so she entered the restroom unaware that Resident #1 was in the restroom. Resident #2 stated Resident #1 cussed at her calling her a bitch. Resident #2 stated Resident #1was standing up blocking the doorway when Resident #2 bumped Resident #1's stomach area with her stomach area. Resident #2 denied grabbing Resident #1. Resident #2 stated that after the bump she left the room. She stated that later the police interviewed her regarding the incident. She moved rooms on 04/05/2025. 455881 Page 2 of 3 455881 04/23/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Attempted phone interview with LVN A on 04/23/2025 at 2:56 p.m. no answer. A message with call back number was left for LVN A. Interview on 04/23/2025 at 12:43 p.m. with Administrator revealed, he was notified of the alleged physical altercation between Residents #1 and #2 on 04/05/2025 by LVN A and he began the abuse investigation. He stated that all parties were notified and Resident #2 was moved to a new room. He stated the risk was that the residents were not in a safe environment. Review of the police report from the [City] Police Department, dated 04/05/25, revealed there were no visible injuries on Resident #1. There were no supported findings. 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. 455881 Page 3 of 3