Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fort Worth Wellness & Rehabilitation during CMS and state inspections, most recent first.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Trash, including used gloves and food containers, was found scattered around outside dumpsters, and the grease-trap-dumpster was left open with residue on top. Dumpsters were accessible to residents and not properly enclosed or covered. Staff interviews confirmed responsibility for maintaining these areas, but also revealed a lack of awareness of the risks and absence of a trash disposal policy.
A CNA was observed standing while feeding a resident with multiple chronic conditions, contrary to facility expectations that staff sit and engage at eye level during meals. The CNA admitted this was not typical practice and recognized the potential risk. Interviews with the ADON and Administrator confirmed that standing while feeding is not acceptable, and the facility could not provide a specific feeding policy when requested.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
A CNA provided toileting care to a resident with a stage 4 sacral pressure ulcer who was on Enhanced Barrier Precautions, but failed to wear required PPE as indicated by physician orders, the care plan, and posted signage. The CNA later acknowledged forgetting to use PPE despite being aware of the resident's condition and precaution status.
The facility did not maintain an effective pest control program, resulting in the presence of roaches in common areas and the dining room, as well as flies in a resident's room, including on the resident's body and bedding. Staff interviews confirmed ongoing pest issues despite regular cleaning and pest control visits, and records showed repeated pest control treatments and a grievance from a family member regarding flies in the resident's room.
A privacy breach occurred when a resident's medical records were mistakenly sent home with another resident and their family. The error involved sensitive information, including diagnoses and insurance details, being disclosed due to a mix-up at the printer by an RN. The facility's policies did not specifically address accidental sharing of PHI.
The facility failed to maintain an effective Infection Prevention and Control Program, leading to potential cross-contamination risks. Two CNAs did not follow proper hand hygiene and glove-changing protocols during incontinent care for a resident, and a medication aide did not sanitize a blood pressure cuff between uses on multiple residents. These actions increased the risk of infection spread among residents with hypertension and cognitive impairments.
The facility failed to maintain an effective pest control program, leading to the presence of gnats and flies in a hallway, dining area, and kitchen. Multiple residents reported discomfort and feelings of uncleanliness due to flies in their rooms. Staff confirmed the issue, noting it had occurred previously. Despite regular pest control treatments, the problem persisted, indicating potential lapses in the implementation of the facility's pest control policy.
A resident's room had maintenance issues, including a missing floor tile, a bent air vent, and a damaged fan, which were not promptly reported or addressed. Staff interviews revealed communication lapses, with the Maintenance Director unaware of the issues until the survey and the Social Worker failing to document them. The DON emphasized the importance of immediate reporting to prevent risks.
A facility failed to properly store a CPAP mask for a resident with sleep apnea, risking contamination and infection. The resident's mask was left on a side table instead of being bagged, contrary to the care plan and facility policy. Staff acknowledged the error, and interviews with the DON and Administrator confirmed the expectation for proper storage to prevent contamination.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly by not maintaining the garbage storage area in a sanitary condition. Observations revealed that trash, including used latex gloves, paper plates, and plastic wrappers, was scattered on the ground around two outside trash dumpsters. The grease-trap-dumpster was found open with greasy residue on top, and none of these areas were bordered or fenced, making them accessible to residents. One dumpster was observed with its sliding door open and half full of trash. These conditions were directly observed during surveyor visits. Interviews with facility staff confirmed that the Director of Maintenance was responsible for keeping the grounds clean and the dumpsters closed, but was unaware of the potential risks associated with trash accumulation. The Dietary Manager stated it was her responsibility to keep the grease-trap-dumpster closed and acknowledged that trash on the grounds could attract pests. The Administrator confirmed expectations for keeping dumpster doors and lids closed and the grounds free of trash, but also stated that the facility did not have a trash disposal policy. Review of facility policy and relevant regulations highlighted the requirement for covered receptacles and regular maintenance, which was not being followed.
Failure to Maintain Resident Dignity and Proper Feeding Technique
Penalty
Summary
A certified nursing assistant (CNA) was observed feeding a female resident with multiple medical conditions, including mild cognitive impairment, psychotic disturbance, difficulty walking, and chronic illnesses such as diabetes and chronic kidney disease. During the observation, the CNA stood over the resident while feeding her tamales with chili cheese, placing the fork in her mouth from a standing position. The CNA acknowledged in an interview that he does not typically stand while feeding residents and explained that someone was in his way at the time. He also recognized that feeding a resident while standing could increase the risk of choking. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that staff are expected to sit and engage with residents during feeding, and that standing over a resident may make them feel rushed or uncomfortable, and prevents the aide and resident from being at eye level. The facility was unable to provide a specific policy for feeding residents when requested, instead submitting a policy for assistive feeding devices. This failure to ensure proper feeding technique and environment did not promote the resident's dignity or quality of life, as required.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Use PPE During Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A certified nursing assistant (CNA) failed to follow established infection prevention and control protocols while providing toileting care to a male resident with a stage 4 sacral pressure ulcer who was on Enhanced Barrier Precautions (EBP). The resident's medical record indicated an active physician order requiring staff to wear a clean gown and gloves during high-contact care activities, including toileting, due to the presence of a wound. The resident's care plan also documented the need for EBP. During an observed care episode, the CNA did not don any personal protective equipment (PPE) despite a posted EBP sign on the resident's door. Upon interview, the CNA acknowledged forgetting to wear PPE and was aware of the resident's wound and EBP status. The assistant director of nursing (ADON) confirmed that the expectation was for staff to adhere to infection control policies, including the use of PPE for residents on EBP. The facility's policy required EBP for activities such as bathing, hygiene, and toileting for residents with indicated precautions.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests and rodents in both a resident's room and public areas. Observations included a roach crawling across the floor near the receptionist's desk, seven flies in a resident's room—five of which were on the resident's body, blanket, or pillow—and a roach on a wall near the dining room trash can. Interviews with staff revealed that pests, mainly small roaches and flies, had been noticed in the facility, and cleaning efforts had not eliminated the problem. The housekeeper reported seeing flies on the resident since the previous Saturday, attributing it to the resident's colostomy bag and associated odor. The maintenance director confirmed that pest control services were provided monthly and that this was the first time he was made aware of the fly issue in the resident's room. The administrator acknowledged that the fly problem had been ongoing for weeks and was not limited to the resident's room, despite pest control visits. Record reviews showed that pest control treatments had been conducted in various facility areas, and a grievance had been filed by the resident's family regarding flies in the room. The facility's pest control policy required staff to report pest sightings and for the housekeeping supervisor to take immediate action, but the presence of pests persisted in both resident and common areas.
Privacy Breach of Resident Medical Records
Penalty
Summary
The facility failed to maintain the privacy of medical records for one resident when a registered nurse (RN A) inadvertently sent another resident's discharge summary and orders home with a different resident and their family. This incident involved Resident #2's medical records being sent with Resident #1 upon their discharge. The error was discovered when a family friend of Resident #1 reported that they had received paperwork belonging to another resident. Resident #1 was a male admitted for orthopedic aftercare following a surgical amputation, while Resident #2 had a history of lung cancer, acute respiratory failure, and was fed via a gastrostomy tube. The discharge note for Resident #1 indicated that he was discharged safely with his family, and his medications and belongings were reviewed with them. However, it was later revealed that Resident #2's medical information, including sensitive details such as Medicaid and Medicare numbers, diagnoses, and medication lists, was mistakenly included in the paperwork given to Resident #1's family. Interviews with the Director of Nursing (DON) and RN A revealed that the error occurred because RN A picked up papers from the printer without realizing that Resident #2's documents were mixed with Resident #1's. The DON and RN A both acknowledged the mistake, and RN A confirmed that she had received training on HIPAA and confidentiality, which emphasized the importance of protecting resident information. The facility's policy on the disclosure of Protected Health Information (PHI) was reviewed, but it did not specifically address accidental sharing of PHI with unauthorized parties.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in potential risks of cross-contamination and infection among residents. Specifically, two CNAs did not adhere to proper hand hygiene and glove-changing protocols while providing incontinent care to a resident with severe cognitive impairment and urinary incontinence. The CNAs did not change gloves or sanitize their hands after removing the resident's shoes and before handling wipes and briefs, and they used improper wiping techniques, which could lead to infections such as urinary tract infections. Additionally, a medication aide failed to sanitize a blood pressure cuff between uses on multiple residents, all of whom had hypertension and required regular blood pressure monitoring. The aide used the same cuff on four different residents without cleaning it, increasing the risk of cross-contamination and infection spread. This oversight was acknowledged by the aide, who admitted forgetting to sanitize the equipment between residents. Interviews with facility staff, including the ADON and DON, confirmed the importance of hand hygiene, glove changes, and equipment sanitization to prevent infection. The staff acknowledged the lapses in protocol and the potential for cross-contamination and infection due to these deficiencies. The facility's policies on hand hygiene, cleaning, and disinfection were reviewed, highlighting the need for adherence to prevent the spread of infections.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and flies in various areas, including one hallway, the dining area, and the kitchen. Observations and interviews revealed that multiple residents experienced flies in their rooms, causing discomfort and feelings of uncleanliness. Residents reported seeing flies for at least a week, and some expressed irritation and dissatisfaction with the facility's cleanliness. Staff members, including a CNA and an LVN, confirmed the presence of flies and noted that this issue had occurred previously during the summer. The facility's pest control log indicated regular treatments, with the most recent being a bi-monthly treatment agreement on May 22, 2024. Despite these treatments, the presence of flies persisted, and the Director of Nursing acknowledged the deficiency in cleanliness caused by the insects. The Administrator stated that the facility contracts with a pest control company and had contacted them as soon as the issue was noticed. However, the pest control policy outlined procedures for staff to report pest sightings, which may not have been effectively implemented, as evidenced by the ongoing issue and lack of immediate resolution.
Failure to Maintain Safe and Comfortable Environment for Resident
Penalty
Summary
The facility failed to ensure a clean and comfortable environment for a resident, identified as Resident #131, who was at risk for injury due to maintenance issues in her room. Observations revealed that the flooring in the resident's room had a missing tile, exposing the concrete floor underneath. Additionally, the air vent behind the resident's bed was bent and partially detached, exposing a hole in the wall. A box fan in the room was also damaged, with its cover separated, exposing the rotating fan blades. These issues were not reported or addressed in a timely manner, despite being noticed by staff. Interviews with facility staff, including the Maintenance Director and the Social Worker, revealed lapses in communication and documentation of maintenance concerns. The Maintenance Director was not informed of the damage until the day of the survey, and the Social Worker, who noticed the issues a week prior, failed to document them in the online maintenance system. The Director of Nursing (DON) confirmed that the expectation was for staff to report maintenance concerns immediately to prevent risks such as injury, improper air flow, and fall hazards.
Improper Storage of CPAP Mask Leads to Deficiency
Penalty
Summary
The facility failed to provide proper respiratory care for a resident who required CPAP therapy for obstructive sleep apnea. The resident, a cognitively intact male with a diagnosis of sleep apnea, was observed to have his CPAP nasal pillow mask improperly stored on a side table instead of being bagged to prevent contamination. This action was inconsistent with the resident's comprehensive care plan and professional standards of practice, which required the mask to be stored in a plastic bag when not in use to prevent infection. During an observation, a Licensed Vocational Nurse (LVN) removed the CPAP mask and placed it on a side table without bagging it, acknowledging the mistake and stating the mask should have been cleaned and bagged. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the expectation was for staff to bag the CPAP mask when not in use to prevent contamination. The facility's policy on oxygen administration also required oxygen items to be stored in a plastic bag to protect them from dust and dirt when not in use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Oaks Health And Rehabilitation Center | 1 mi | ★★★★★ | 16 | 2 |
| Marine Creek Nursing And Rehabilitation | 2 mi | ★★★★★ | 18 | 0 |
| Lake Lodge Nursing & Rehabilitation | 3.1 mi | ★★★★★ | 12 | 0 |
| White Settlement Nursing Center | 3.9 mi | ★★★★★ | 6 | 0 |
| The Stayton At Museum Way | 4.1 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.