Health 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 Page 1 of 2 455881 455881 06/18/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0773 sugar levels over the past 2-3 months) every three months. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's electronic clinical record from June 1 - June 30, 2025 revealed there were no labs results for April 2025 for the CBC, CMP, lipid and Valproic acid and no lab results for January 2025 or April 2025 for the Hgb and A1C. Residents Affected - Some Interview on 06/18/25 at 12:00 PM with the DON revealed after searching she did not find the lab results ordered for Resident #1 for January 2025 or April 2025. The DON stated Resident #1 has a history of refusing care and will become combative with staff however in this case I don't have documentation to support that the blood draw completed or was refused by Resident #1. The DON stated all physician orders including labs should be completed as ordered. The DON stated if a lab was refused it should be documented. The DON stated the risk of not doing the labs as ordered could result in not having a clear picture of the resident. Interview on 06/18/25 with the Administrator was not obtained since he was out of the facility that day. Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised November 2018 revealed The physician will identify, and order diagnostic lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. Review of the facility policy titled Medication and Treatment Orders, revision date of July 2016 revealed Orders for medications and treatments will be consistent with principles of safe and effective order writing . 455881 Page 2 of 2