Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ft. Worth Southwest Nursing Center during CMS and state inspections, most recent first.
Improper Storage of Zinc Oxide Ointment: Staff observed 2 tubes of Zinc Oxide ointment in an open resident drawer and 10 tubes in linen cart side pockets instead of locked medication storage. CNAs and the Restorative Aide confirmed the ointment was kept in resident drawers and cart pockets for use on residents, and the DON stated it was left readily available for staff use. The facility policy required meds and biologicals to be stored safely and securely and locked when not attended by authorized personnel.
Unsafe Resident Room Environment Due to Severe Hoarding: A resident with anxiety, depression, psychotic features, and intact cognition had a room filled with purchases and other items on both sides of the room, leaving only a narrow path to the bed. The bathroom was also cluttered, and molded bread was observed on top of the refrigerator. The care plan noted hoarding behavior, refusal to let staff remove items, and keeping mayonnaise in the room despite education about refrigeration.
Residents were not invited or documented as participating in their care plan conferences, and their care conferences were overdue. Two cognitively intact residents and one resident with moderate cognitive impairment each reported they had not received notice of a care conference or a copy of their care plan. The DON and Administrator acknowledged the care conference process needed improvement, and the facility policy required the resident and/or representative to be included in the IDT care planning process.
Food storage and handwashing sink waste receptacle deficiencies were identified in the kitchen. Handwashing sink garbage receptacles contained items other than disposable paper towels, including used gloves and plastic wrap, and an LDM was observed placing dirty gloves in a sink receptacle. In dry storage, multiple canned goods had dents or compromised seals, and in the walk-in refrigerator, several items were improperly dated, including products past their out date.
A facility failed to maintain catheter care infection control for 3 residents. One resident’s foley bag touched a fall mat at the bedside, and two residents’ catheter bags hung under their wheelchairs and touched the floor during PT. The residents had significant medical histories including CHF, CKD, MRSA, sepsis, chronic osteomyelitis, and indwelling catheter-related infection, and staff stated catheter bags should be kept below the bladder and off the floor.
Failure to provide written transfer/discharge notices and Ombudsman notification. Two residents were sent to the hospital, but neither received a written notice explaining the transfer/discharge, the reason for the move, or appeal rights, and no copy was sent to the State LTC Ombudsman. The Social Worker, DON, and Administrator each described that the facility relied on transfer sheets or monthly lists rather than providing the required written notices.
A resident with epilepsy, dementia, schizophrenia, bipolar disorder, and other diagnoses was found with electronic cigarettes in her room and later in the seat of her rollator. Staff had previously found a vape in her possession, and progress notes documented repeated smoking-policy violations, including smoking after hours and asking staff to help her obtain a vape. Interviews confirmed that e-cigarettes were not allowed in resident rooms and that the facility's smoking policy required smoking materials to be stored securely and smoking sessions to be supervised by staff.
Two residents experienced deficiencies in their living environment, with one room found unclean and containing food debris and sticky surfaces, and another room having a broken window with cracks and an open area left unrepaired. These issues persisted despite prior complaints and awareness by facility staff.
Staff failed to secure a tube of zinc oxide ointment and a bottle of antiseptic skin cleanser, leaving them in a resident's room after use. The items were discovered during observation, and interviews confirmed that an aide had left the ointment behind while rushing to assist another resident. Facility policy prohibits leaving medications at the bedside, and both nursing and administrative staff acknowledged the lapse.
A resident with multiple chronic conditions and moderate cognitive impairment refused to leave the courtyard until early morning hours, and although an LVN checked on the resident regularly, no timely documentation was made in the clinical record as required by facility policy. The incident was only recorded days later as a late entry.
A resident with moderate cognitive impairment and multiple medical conditions was transferred from a wheelchair to a bed by two CNAs without the use of a gait belt, contrary to the resident's care plan and facility policy. Both CNAs acknowledged awareness of the requirement and had received training, but did not use the assistive device during the observed transfer. Interviews with additional staff confirmed that the use of a gait belt was expected for all transfers unless contraindicated.
A medication cart on one hall was found unlocked and unattended, with no staff in view, contrary to facility policy. Staff interviews confirmed that the cart should be locked when not in use to prevent unauthorized access to medications.
A facility failed to maintain a clean and safe environment for residents in the 100 Hallway, where A/C vents in several rooms were found to be dusty and unclean. This affected residents with medical conditions such as COPD and chronic respiratory failure, who expressed concerns about air quality. Interviews revealed a lack of awareness and communication among staff regarding vent maintenance, with no entries in the Maintenance Request Log for the issue. The Housekeeping Supervisor and DON were unaware of the problem, and the facility's cleaning policy lacked guidance on vent maintenance.
A resident was administered the incorrect form of morphine due to a transcription error and oversight by staff. The resident was prescribed morphine sulfate 15 mg for pain, but received morphine sulfate ER 15 mg instead. The error went undetected for several weeks, with multiple staff members failing to verify the medication against the physician's order. The facility's policy on medication administration was not followed, leading to the discrepancy.
A LTC facility experienced a 9% medication error rate involving two residents. One resident received crushed Depakote DR, contrary to instructions, due to a misunderstanding by a medication aide. Another resident was given extended-release morphine instead of the prescribed immediate-release form, along with an incorrect laxative dose. These errors were due to transcription mistakes and failure to verify medication orders.
The facility failed to maintain an effective infection prevention and control program, as evidenced by inadequate incontinence care for two residents, unclean pill crushers on medication carts, and dirty washing machines. CNAs did not change gloves or perform hand hygiene during care, and pill crushers were not properly cleaned, posing potential infection risks. Additionally, the washing machines had inaccessible areas that were not cleaned, further compromising infection control.
A facility failed to ensure accurate PASRR Level I screening for a resident with a mental disorder, specifically bipolar disorder, leading to a risk of inadequate services. The MDS Coordinator did not submit a correction form upon noting the resident's mental illness diagnoses, and the DON acknowledged the risk of incorrect PASRRs. Facility policy required screening for mental illness prior to admission.
The facility failed to implement baseline care plans within 48 hours of admission for residents, as required by policy. A resident with acute on chronic diastolic heart failure and a methicillin-resistant staphylococcus aureus infection did not have a care plan completed until several days post-admission. The ADON misunderstood the timeframe requirement, and there was no plan for weekend admissions, risking effective and person-centered care.
A male resident with severe cognitive impairment and incontinence was not properly cleaned during incontinence care, as a CNA failed to clean the genital area, increasing the risk of infection. Interviews confirmed the importance of cleaning to prevent infection, and the facility's protocol was not followed.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident who was found in her bed with his pants off. The facility failed to immediately investigate, report the incident, or place the alleged perpetrator under supervision, violating their abuse prevention policy. This led to a finding of Immediate Jeopardy and Substandard Quality of Care.
A long-term care facility failed to implement its abuse prevention policies when a resident with severe cognitive impairments was found in a potentially abusive situation with another resident. The facility did not investigate or report the incident promptly, leaving residents at risk. Staff interviews revealed a lack of communication and adherence to reporting procedures, resulting in an Immediate Jeopardy situation.
A facility failed to investigate and report an alleged sexual assault involving two residents. A female resident with severe cognitive impairment was found in bed with a male resident who had no cognitive impairment. The facility did not follow its abuse prevention and reporting policies, failing to initiate an investigation or notify authorities promptly. The DON did not complete an incident report, and the male resident was not placed under supervision until days later. This inaction placed residents at risk for abuse and psychosocial harm.
Improper Storage of Zinc Oxide Ointment
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments under proper temperature controls and to limit access to authorized personnel. During observation, two 1 oz tubes of Zinc Oxide ointment were found in an open top drawer in a resident room. Additional observations showed Zinc Oxide ointment stored in linen cart side pockets, including 2 tubes at one observation, 3 tubes at another, and 5 tubes at another, for a total of 10 tubes observed on three linen carts. The ointment was being kept outside of locked medication storage areas. During interviews, CNA A stated the Zinc Oxide ointment was kept in resident drawers and in the pockets of linen carts for use on residents with skin breakdown. CNA B stated that when she opened a tube of Zinc Oxide ointment, she carried it with her and used it on each resident until it was gone. The Restorative Aide confirmed the ointment was found in a resident top drawer and in the side pocket of the linen cart. The Treatment Nurse stated the ointment was purchased from the supply vendor, not the pharmacy, and was used as a preventive measure to prevent resident skin breakdown. The DON stated the ointment was readily available inside the linen cart pockets for staff use and said there was no risk to residents because it was like lotion. The facility policy stated medications and biologicals are to be stored safely and securely, and medication rooms, carts, and supplies are to be locked when not attended by authorized personnel.
Unsafe Resident Room Environment Due to Severe Hoarding
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident. Resident #1, a [AGE]-year-old female with diagnoses including unsteadiness of feet, generalized anxiety disorder, major depressive disorder, recurrent severe depressive disorder with psychotic features, and cognitive communication deficiency, had a care plan noting hoarding behavior, refusal to allow staff to remove purchases, and keeping mayonnaise in her room despite education that it needed refrigeration. The care plan also noted that she had so many items in the room that they took up both sides of the room and that she had called police to the facility when asked to clean. Her quarterly MDS reflected a BIMS of 15, indicating intact cognition. During observation, Resident #1's bathroom was full of items on the floor and stacked along the walls, both sides of the room were filled with different items, and there was only a narrow path approximately 1 foot wide from the door to the bed. Molded bread was observed on top of her refrigerator. The resident stated she could not clean her room because her hip hurt and she did not have time, and she said she did not like all the staff in her room. Record review showed no documentation from 03/20/26 to 05/20/26 related to the facility's efforts to address the hoarding and shopping behaviors.
Residents Not Included in Care Plan Conferences
Penalty
Summary
The facility failed to ensure that Resident #2, Resident #3, and Resident #76, or their representatives, were invited and given the opportunity to participate in their person-centered care plan meetings. The report states that these residents were reviewed for comprehensive care planning and that no documentation was found in the EMR showing they had been invited to or participated in their care conferences. The facility’s own policy required the resident and/or representative to be included in the comprehensive care plan process, and to receive a written summary of the baseline care plan. Resident #2 was a cognitively intact male with diagnoses including depression, generalized anxiety disorder, PTSD, and dysphagia. His MDS showed a BIMS score of 14/15 and he required partial to moderate assistance with toileting, bathing, and lower body dressing. On review of the EMR, his care conference was 11 days overdue, and there was no documentation that he had been invited or participated. During interview, he stated he had never received notice of a care conference or care plan meeting and had never been given a copy of his care plan, and he expressed concern about not being involved in his care or having his care provided according to his preferences. Resident #3 was also cognitively intact with a BIMS score of 15/15 and diagnoses including acute hematogenous osteomyelitis, asthma, morbid obesity, atherosclerotic heart disease, ESRD, and atrial fibrillation. He required substantial to maximal assistance with toileting, bathing, lower body dressing, and footwear. His care conference was 42 days overdue, with no documentation of invitation or participation. Resident #76 had a BIMS score of 11/15 and moderate cognitive impairment, with diagnoses including muscle atrophy, contractures, major depressive disorder, dysphagia, and cognitive communication deficit; he required dependent assistance with multiple ADLs. His care conference was 16 days overdue, and there was no documentation that he had been invited or participated. He stated he did not remember receiving notice of a care conference or care plan meeting and had never been given a copy of his care plan, and said he would have liked to be involved in his care.
Food Storage and Handwashing Sink Waste Receptacle Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen reviewed for food safety. During observations, the garbage receptacles at handwashing sinks #1 and #2 contained items other than disposable paper towels, including used gloves, plastic wrapping, and paper. The Dietary Manager was observed placing dirty gloves in the #2 sink garbage receptacle and stated she had always disposed of dirty gloves in the #1 and #2 sink receptacles and had not known this was inappropriate. In the dry storage room, several canned goods were observed with compromised seals or dents, including cream of celery soup with two dents on the bottom seal, diced pears with a dent on the side of the can, tomato juice with a dent on the bottom seal, and refried beans with a dent on the top seal. In the walk-in refrigerator, sliced dill pickles, prepared mustard, and teriyaki sauce were observed with received, open, and out dates written on the containers, and the pickles and mustard were also noted as being past the out date. The Dietary Manager stated that staff inspecting deliveries were responsible for checking cans for dents, that damaged cans were placed on a designated shelf and returned for credit, and that refrigerated products should have received, opened, and out dates written on them.
Catheter Bags Contacted the Floor During Care and Therapy
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for catheter care for 3 of 6 residents reviewed for infection control. Resident #14, a male on hospice with diagnoses including atherosclerotic heart disease, congestive heart failure, cerebral infarction, and hypertension, had a foley catheter and a care plan intervention to keep the drainage bag off the floor. During observation, his catheter bag was touching his fall mat at the bedside while he was sleeping. The resident was also care planned for falls, a low bed, and enhanced barrier precautions due to the foley catheter. Resident #1, a male with chronic osteomyelitis, sepsis, proteus infection and inflammatory reaction due to an indwelling urethral catheter, vancomycin resistance, MRSA infection, acute cystitis, metabolic encephalopathy, and cognitive communication deficit, had a care plan that included a foley catheter and keeping the drainage bag off the floor. Resident #122, a female with heart failure, stage 4 chronic kidney disease, and neuromuscular dysfunction of the bladder, also had catheter care needs. During an observation in the physical therapy room, Residents #1 and #122 were sitting in wheelchairs with their catheter bags hanging under the wheelchairs and touching the floor. Staff interviews stated catheter bags should be kept off the floor and below the bladder, and the facility policy required collection bags to avoid contact with the floor at any time.
Failure to Provide Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to notify two residents and/or their representatives in writing of transfer or discharge, the reasons for the move, and their right to appeal, and it also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The deficiency involved Resident #32 and Resident #139, both of whom were sent to the hospital from the facility without evidence of the required written transfer or discharge notice or Ombudsman notification. Resident #32 was a cognitively intact female with diagnoses including COPD, cognitive communication deficit, type 2 diabetes mellitus without complications, and atherosclerotic heart disease. Her MDS reflected a BIMS score of 15/15. A progress note documented that she complained of chest pain and shortness of breath and was sent to the hospital. During interview, she stated she never received a written letter when she was sent to the emergency room and said she would have liked to receive one so she could review it later. Resident #139 was a female with diagnoses including metabolic encephalopathy, dysphagia, cognitive communication deficit, obstructive sleep apnea, and COPD. Her MDS reflected a BIMS score of 11/15, indicating moderate cognitive impairment, and she required dependent to substantial/maximal assistance with care. A progress note documented altered mental status and an order to send her to the hospital. During interview, she stated she never received a written letter when she was sent to the emergency room and would have liked to receive one so she could review it later. The Social Worker stated she had not provided written notification to the residents or their representatives regarding the transfer or discharge, including the reason for the transfer or discharge, and had not sent a copy of the notice or a list of discharged residents to the State LTC Ombudsman because she thought someone else at the facility sent them. The DON stated nursing staff only provided a transfer sheet to the hospital and that the hospital sent clinicals back when the resident returned. The Administrator stated the facility did not provide letters to residents or their representatives when they discharged to the hospital, and that the Social Worker sent a monthly list of residents who had been discharged to the State LTC Ombudsman.
Resident Kept Electronic Cigarettes in Room and Rollator
Penalty
Summary
The facility failed to ensure that Resident #72 was free from accident hazards when electronic cigarettes were found in her room and in her rollator seat. Resident #72 was admitted with diagnoses including idiopathic epilepsy, abnormal gait and mobility, type 2 diabetes, mild cognitive impairment, dementia, schizophrenia, bipolar disorder, and major depressive disorder. Her MDS showed a BIMs score of 15, and she was assessed as an active tobacco user. Her care plan addressed behavior problems, resistance to care, and prior findings of a nicotine vape in her possession, with interventions focused on protecting the rights and safety of others and educating the resident and family. Progress notes showed repeated smoking-related noncompliance. On 02/03/2026, staff found a vape in her possession and provided education about the smoking policy. On 04/27/2026, she was seen in the courtyard smoking after hours, then asked staff to buy her a vape or transport her to a gas station to get one, which staff told her was prohibited. During observation on 05/06/2026, the surveyor saw Resident #72 with an object near her mouth in her room; she placed it into the seat of her rollator when the surveyor made eye contact. She told the surveyor she used electronic cigarettes and said the facility had a locked box for smoking devices, and that she charged her own electronic cigarettes during smoking times. During a later observation on 05/07/2026, the surveyor saw two electronic cigarettes in the seat of her rollator after she opened the lid to answer a phone call. Staff interviews confirmed that electronic cigarettes had been found in her room before and that residents were not allowed to smoke or use e-cigarettes in their rooms. The social worker and administrator stated they removed electronic cigarettes from her room after reviewing hospital records that indicated she had used her e-cigarette in the hospital waiting room. The facility's smoking policy stated that smoking is not allowed inside the facility, applies to cigarettes and e-cigarettes, requires smoking materials to be stored in a secure area, and requires all smoking sessions to be supervised by staff.
Failure to Maintain Cleanliness and Repair in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents. In one instance, a male resident's room was observed to have large brown crumbs on the floor near the television, cheese balls under the edge of the bed, and a sticky fall mat with crumbs on it. Although some cleaning was performed later in the day, cheese balls and sticky spots remained. The resident did not respond to the surveyor during the observation. The resident's family member reported having previously complained about the room's cleanliness, particularly on weekends when fewer housekeepers were present. In another instance, a female resident's room had a broken window with large cracks, some of which were covered with green tape, and an open area with no coverage. The window was open, and the resident was unaware of the extent of the damage. The Maintenance Director, who had recently started at the facility, acknowledged the broken window and stated that materials had been purchased for repair. The facility's policy requires that all residents be treated with respect and dignity in an environment that promotes quality of life, but these conditions were not met for the two residents involved.
Drugs and Biologicals Left Unsecured in Resident Room
Penalty
Summary
Staff failed to store all drugs and biologicals in locked compartments as required, resulting in a tube of uncapped Zinc Oxide ointment and a bottle of Antiseptic Skin Cleanser being left in a resident's room. During observation, these items were found on the resident's nightstand and refrigerator, respectively. The resident reported that staff must have left the items in the room that morning and confirmed that staff typically keep all medications. Interviews with nursing staff revealed that an aide had applied the zinc oxide ointment earlier and inadvertently left it behind while responding to another call light. The nurse was unsure about the origin of the antiseptic cleanser and confirmed that such items should not be left in resident rooms. Facility policy explicitly states that medications are not to be left at the bedside. Both the Director of Nursing and the Administrator acknowledged during interviews that these items should not have been left in the resident's room. The staff involved admitted to being aware of the policy but failed to follow it due to being rushed, resulting in unauthorized access to medications and biologicals.
Failure to Timely Document Resident Refusal and Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, there was no timely documentation regarding a resident's refusal to leave the facility's courtyard until 1:00 AM, despite the resident being checked on multiple times by an LVN during the night. The LVN stated that he was informed by the previous shift that the resident was in the courtyard and not ready to return inside, and he continued to check on the resident every 20-30 minutes. However, no progress note was entered into the electronic record at the time of the incident to reflect the resident's actions or the staff's monitoring. The resident involved had multiple diagnoses, including Parkinson's Disease, Type 2 Diabetes, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, chronic pain, visual impairment, hypertension, COPD, and dysphagia, and was assessed as having moderate cognitive impairment. The lack of timely documentation was only addressed days later with a late entry note. The facility's own policy required nursing documentation to be completed by the end of the assigned shift, which was not followed in this instance.
Failure to Use Required Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and the required assistive device during a transfer, as observed during a staff interaction. Specifically, two CNAs transferred a male resident with moderate cognitive impairment, multiple medical diagnoses including Parkinson's disease, diabetes, and blindness, from a wheelchair to a bed without using a gait belt, despite this being a documented requirement in the resident's care plan and facility policy. Both CNAs lifted the resident by placing their arms under his arms and pulling him to a standing position before pivoting him to the bed. Interviews with the involved CNAs revealed that they were aware of the requirement to use a gait belt for transfers and had previously received in-service training on this procedure. Both staff members acknowledged that not using a gait belt posed risks to the resident, including falls and injuries, and admitted there was no reason for not following the protocol during the observed transfer. Additional interviews with an LVN and the DON confirmed that the expectation was for all transfers to be performed with a gait belt unless contraindicated, and that the resident in question had no restrictions for gait belt use. A review of the facility's transfer policy further supported that residents requiring assistance should be transferred using a gait or transfer belt, and that staff are trained to use proper procedures and assistive devices. The policy outlines specific steps for two-person assisted transfers, including the application of a gait belt, which was not followed in this instance. This lapse in protocol was directly observed and confirmed through staff interviews and record review.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart located on the 400 hall was observed to be unlocked and unattended, with no staff in view. The cart was parked at the nursing station with its drawers facing the hallway and exit doors. This observation was made at 6:45 AM, and it was later noted that a nurse returned to the cart and accessed it. Multiple staff interviews confirmed that the medication cart should be locked when not in use or when not in direct view of authorized personnel. Record review of the facility's medication storage policy indicated that medications and biologicals are to be stored securely and are accessible only to authorized staff. The policy also requires that medication carts be locked when unattended. Staff members, including an LVN, RN, MA, and the DON, all acknowledged during interviews that the cart should be locked to prevent unauthorized access, in accordance with facility policy.
Failure to Maintain Clean A/C Vents in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, particularly in the 100 Hallway, where the A/C vents in several rooms were found to be dusty and unclean. This deficiency was observed in the rooms of three residents, all of whom had medical conditions that could be exacerbated by poor air quality. Resident #27, who had intact cognition, reported a dry cough and was unaware of the dusty vents above her bed. Resident #99, who was on hospice care for chronic respiratory failure and COPD, also expressed concerns about the air quality due to the unclean vents. Resident #107, with severe cognitive impairment, was observed coughing and was unaware of the dust in the vent above her bed. Interviews with facility staff revealed a lack of awareness and communication regarding the maintenance of A/C vents. The Maintenance Director acknowledged the issue and stated that both the Maintenance and Housekeeping Departments were responsible for ensuring the cleanliness of the vents. However, Maintenance Staff L and CNAs M and N were unaware of the unclean vents until it was brought to their attention by a State Surveyor. The Maintenance Request Log, which should have been used to report such issues, contained no entries regarding the dusty vents, indicating a breakdown in the reporting process. The Housekeeping Supervisor admitted to being unaware of the unclean vents and stated that there was no schedule for cleaning them. The DON also expressed unawareness of the issue and emphasized that the responsibility for cleaning the vents lay with the Maintenance and Housekeeping Departments. Despite acknowledging the potential harm from unclean vents, the DON downplayed the risk by comparing it to common household conditions. The facility's Resident Room Cleaning policy did not provide guidance on cleaning A/C vents, contributing to the oversight.
Failure to Administer Correct Medication Dosage
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident, resulting in the administration of the incorrect form of morphine. The resident was prescribed morphine sulfate 15 mg to be taken twice daily for pain management. However, the pharmacy delivered morphine sulfate ER (extended release) 15 mg tablets, which were administered 37 times over a period of several weeks without the discrepancy being detected until a surveyor inquiry. The resident, who was cognitively intact and had a history of hypertension and a fracture, was at risk of not receiving the intended therapeutic effect of the medication due to the error. The discrepancy was overlooked by multiple staff members, including LVNs and RNs, who failed to verify the medication against the physician's order during administration. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the error until it was brought to their attention by the surveyor. The facility's policy on oral medication administration requires that medication orders be reviewed and confirmed prior to administration, but this procedure was not followed. The error was attributed to a transcription mistake during a medication reorder, and the staff responsible for checking in and administering the medication did not catch the discrepancy. The DON acknowledged that the Charge Nurse is ultimately responsible for ensuring that medications administered match the physician's orders.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9% error rate based on 3 errors out of 32 opportunities. This involved two residents, one of whom was administered a medication incorrectly due to a misunderstanding of medication instructions. Specifically, a medication aide crushed Depakote DR, a delayed-release medication that should not be crushed, for a resident with severe cognitive impairment. The aide was unaware of the significance of the 'DR' notation and did not see the 'do not crush' instruction on the medication card, leading to the potential for adverse side effects. Another error involved a resident who was given the wrong form of morphine. Instead of the prescribed immediate-release morphine, the resident received an extended-release version. Additionally, the resident was administered a generic form of a laxative that did not include the prescribed docusate, increasing the risk of constipation. These errors were attributed to a transcription mistake and a failure to verify medication orders against the medication being administered. The facility's policy on oral medication administration requires confirmation of medication orders and adherence to crushing guidelines, which were not followed in these instances. The errors were identified during a surveyor's observation and interviews with facility staff, highlighting lapses in medication administration procedures and staff training.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Two residents, both with severely impaired cognitive status and dependent on staff for toileting, were subjected to inadequate incontinence care. In both cases, the CNAs did not change gloves or perform hand hygiene during the care process, which is a critical step in preventing cross-contamination and infection. Additionally, one CNA failed to clean a resident's penis, despite acknowledging its importance in infection prevention. The survey also revealed that the pill crushers on three medication carts were not properly cleaned. Observations showed that the backs of the pill crushers were dirty, with dust, rust, and other substances present. The staff responsible for cleaning these devices admitted to not cleaning all parts of the pill crushers, which could lead to potential infection risks, although the facility's DON believed there was no risk due to the use of pill crusher plastic bags. Furthermore, the facility's two washing machines were found to be dirty, with a crusty-tan substance on the inner rings of the front-loading doors. The laundry staff and maintenance director acknowledged the issue, noting that the areas were difficult to access and clean. The facility lacked a specific policy for cleaning the washing machines, relying instead on cleaning them when visibly soiled. These deficiencies collectively placed residents at risk for healthcare-associated cross-contamination and infections.
Failure to Ensure Accurate PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that individuals with mental disorders were properly evaluated and received care in the most integrated setting appropriate to their needs. This deficiency was identified for one resident who was reviewed for PASRR Level I screenings. The PASRR Level I Screening for the resident, dated 10/25/2023, did not correctly identify the resident as having a mental illness, specifically bipolar disorder, which had an onset date of 10/25/2023. The failure to complete a new PASRR Level I Screening placed the resident at risk of not receiving adequate services or care related to their mental illnesses. The deficiency was further highlighted during interviews with facility staff. The MDS Coordinator admitted to submitting the PASRR information as provided by the resident's previous facility and did not send a correction form upon noting the resident's mental illness diagnoses. The Director of Nursing (DON) stated that the MDS nurses were responsible for ensuring the PASRRs were complete and accurate, and the risk of incorrect PASRRs was that residents might not get access to services for which they qualify. The facility's policy required that all applicants be screened for mental illness and/or intellectual disability prior to admission, and a positive Level I screen necessitated an in-depth evaluation by the state-designated authority, known as PASRR Level II.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for residents within 48 hours of admission, as required by their policy. This deficiency was identified for one resident among those reviewed. Specifically, the baseline care plan for a resident with acute on chronic diastolic heart failure and a methicillin-resistant staphylococcus aureus infection was not completed until several days after admission. The delay in creating the care plan meant that the resident's immediate healthcare needs, including physician orders, dietary orders, therapy services, and social services, were not addressed in a timely manner. During an interview, the Assistant Director of Nursing (ADON) expressed a misunderstanding of the required timeframe for completing baseline care plans, believing it to be 72 hours instead of the mandated 48 hours. Additionally, there was no plan in place to ensure the completion of baseline care plans over the weekend, as these were typically handled by various department heads. This oversight placed residents at risk of not receiving effective and person-centered care, as the facility's policy clearly stated the requirement for a baseline care plan to be developed within 48 hours of admission.
Inadequate Incontinence Care for Male Resident
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, a male with severe cognitive impairment and diagnoses including heart failure, renal failure, and diabetes, was always incontinent of bowel and bladder and dependent on staff for toileting. During an observation, a CNA did not thoroughly clean the resident's genital area during incontinence care. Specifically, the CNA cleaned the peri-area and inner thighs but did not clean the penis or foreskin, and did not change gloves or perform hand hygiene before applying a new brief. Interviews with the CNA, the Infection Preventionist, and the Director of Nursing confirmed that the facility's protocol required cleaning the penis to prevent infection. The CNA stated that the resident did not like his penis to be cleaned, but acknowledged the importance of cleaning to reduce infection risk. The facility's competency evaluation for pericare also outlined the proper procedure for cleaning a male resident, which was not followed in this instance.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident who was found in her bed with his pants off. The resident, who was unable to give consent due to severe cognitive impairment, was discovered in a compromising situation with another resident who had no cognitive impairment and was independent in his activities of daily living. Despite the serious nature of the incident, the facility did not immediately implement protective measures or conduct a thorough investigation. The Director of Nursing (DON) and other staff members did not take appropriate actions following the incident. The DON did not initiate an investigation or report the incident to law enforcement or the state agency. The resident was not sent for a Sexual Assault Nurse Examiner (SANE) exam immediately, and the alleged perpetrator was not placed under supervision until days later. Staff members assumed that the resident could consent, despite her severely impaired cognition, and did not follow the facility's abuse prevention policy. Interviews with staff revealed a lack of immediate response and failure to follow protocol. The DON and other staff members did not document the incident properly or ensure the safety of all residents by placing the alleged perpetrator under supervision. The facility's policy required immediate reporting and investigation of such incidents, but these steps were not taken, leading to a finding of Immediate Jeopardy and Substandard Quality of Care.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case involving two residents. Resident #1, a female with severe cognitive impairments and multiple diagnoses including aphasia and major depressive disorder, was found in a potentially abusive situation with Resident #2, a male resident with no cognitive impairment but a history of mental health issues. On 06/30/2024, Resident #2 was discovered in Resident #1's bed, and although no immediate physical harm was noted, the situation raised concerns about potential sexual abuse. The facility did not follow its policy to investigate the alleged or suspected sexual abuse of Resident #1. The Director of Nursing (DON) and other staff members failed to initiate an immediate investigation or report the incident to the proper authorities, including law enforcement and state agencies. Despite being informed of the incident, the DON did not consider it necessary to investigate further or place Resident #2 under supervision until several days later. This lack of action left Resident #1 and other residents potentially vulnerable to further incidents. Interviews with staff revealed a breakdown in communication and reporting procedures. Some staff members assumed the incident had been reported and addressed, while others did not document or report their observations. The facility's policy required immediate reporting and investigation of such incidents, but these steps were not taken promptly, leading to an Immediate Jeopardy (IJ) situation being identified by surveyors on 07/03/2024.
Failure to Investigate and Report Alleged Sexual Assault
Penalty
Summary
The facility failed to thoroughly investigate and report an alleged incident of sexual assault involving two residents. Resident #1, a female with severe cognitive impairment and communication difficulties, was found in bed with Resident #2, a male resident with no cognitive impairment but a history of mental health issues. The incident was initially reported by a CNA who found Resident #2 in Resident #1's bed, but the facility did not immediately initiate a comprehensive investigation or report the incident to the appropriate authorities. The Director of Nursing (DON) and other staff members did not follow the facility's abuse prevention and reporting policies. Despite being informed of the situation, the DON did not complete an incident report or initiate an investigation, and Resident #2 was not placed under supervision until several days later. The facility also failed to send Resident #1 for a Sexual Assault Nurse Examiner (SANE) exam or notify law enforcement promptly. Interviews with staff revealed a lack of immediate action and communication regarding the incident, with some staff assuming the issue had been reported and addressed. The facility's inaction and failure to adhere to established protocols placed residents at risk for abuse and psychosocial harm. The DON and other staff members did not validate the information they received or take necessary steps to ensure the safety of all residents. The incident was not discussed in management meetings, and the facility did not ensure that all staff were aware of and trained in the abuse prevention and reporting policies, leading to a delay in addressing the situation appropriately.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 749 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Avir At Fort Worth | 0.2 mi | ★★★★★ | 19 | 2 |
| Wedgewood Nursing Home | 0.5 mi | ★★★★★ | 16 | 0 |
| Ignite Medical Resort Fort Worth, Llc | 1.3 mi | ★★★★★ | 17 | 0 |
| Mira Vista Court | 1.5 mi | ★★★★★ | 2 | 0 |
| Garden Terrace Healthcare Center Of Fort Worth | 1.7 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.