Health inspection·May 11, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interviews, and record reviews the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 4 residents (Resident #3) whose assessments were reviewed, in that: The facility failed to ensure that Resident #3's MDS assessment correctly noted the resident's weight loss of 10% percent in 6 months. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings were: A record review of Resident #3's EHR revealed an [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #3's diagnoses included Metabolic encephalopathy, Acute Respiratory Failure, and Dementia with Lewy body. A review of Resident #3's annual MDS dated [DATE] revealed a BIMS score of 03, indicating the resident had severe cognition impairment. A review of section K: Swallowing/ Nutritional Status revealed a weight of 144 lbs. Further review of the section revealed Resident #3 had no weight loss of 5% or more in the last month and 10% or more in the last 6 months. A review of Resident #3's weight log on EHR revealed the following: 10/10/22-161.6 lbs. 11/02/22- 153 lbs. 12/02/22- 155 lbs. 01/04/23- 149.6 lbs. 02/09/23- 148.2 lbs. 03/06/23- 146.0 lbs. 04/12/23- 144.0 lbs. (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 4 Event ID: 676161 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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)