Inspection·June 18, 2025

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to provide or obtain laboratory services only when ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for one (Resident #1) of two residents reviewed for labs. 1. Nursing staff did not ensure that labs (CBC, CMP, lipid, Valproic acid) were drawn every six months for Resident #1. 2. Nursing staff did not ensure that labs (Hgb and A1C) were drawn every three months for Resident #1. These failures could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition. Findings included: Review of Resident #1's face sheet dated 06/18/25 revealed a [AGE] year-old male with an admission date of 12/15/2023. Diagnoses included: metabolic encephalopathy (condition when brain dysfunction occurs), severe protein-calorie malnutrition (condition of inadequate intake of both protein and calories), anemia (blood doesn't have enough healthy red blood cells), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using energy), dipolar disorder (episodes of mood swings ranging from depressive lows to manic highs) and paranoid disorder (unrealistic distrust of others). Review of an MDS assessment dated [DATE] revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. Review of Resident #1's care plan with date initiated of 12/16/23 with a target date of 08/23/25 revealed Focus: Anemia, Goal: Lab work will be within normal limits during this quarter, Interventions/Tasks: Obtain lab as ordered, report abnormal values to physician . Review of Resident #1's electronic physician orders for June 2025 revealed an ordered dated 10/17/24 for CBC (measures varies components of your blood), CMP (blood test that measures fourteen different substances in the blood), lipid (broad group of organic compounds which include fats, waxes, sterols, fat-soluble vitamins, monoglycerides, diglycerides, phospholipids, and others), and Valproic acid (is a blood test to measure the concentration of valproic acid in the bloodstream) every six months and Hgb (a protein in red blood cells) and A1C (is a blood test that provides an average of blood (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 2 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 06/18/2025 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)