Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Ignite Medical Resort Fort Worth, Llc during CMS and state inspections, most recent first.
Improper Food Storage and Labeling in Kitchen: The facility failed to keep food items in the kitchen sealed, dated, labeled, and stored off the floor. Surveyors observed opened lettuce scattered in the walk-in refrigerator, unlabeled and undated potato salad and pudding, undated lemonade and tea in the reach-in refrigerator, and dry storage items including unsealed cups, a cracked honey jar leaking onto the floor, and an orange on the floor. The Dietary Manager said she was new and had not had time to make corrective changes, and the Administrator said food storage oversight was the Dietary Manager's responsibility.
Improper Garbage Receptacle Storage and Disposal: The facility failed to keep kitchen trash cans covered when not in use and failed to maintain the outside dumpster area in a sanitary condition. Observations found open trash cans, a trash box on top of a can, a lid propped open, a full dumpster with doors open, trash bags hanging outside, and debris on the ground around the dumpster. The Maintenance Director and Dietary Manager identified responsibility for the dumpster area and kitchen trash lids, and the facility policy required receptacles to be kept covered and sanitary.
An unlocked treatment cart was found unattended in a hallway with wound care supplies, betadine, and prescription medication inside, and staff could not identify who left it open. In a separate observation, an LPN left a med cart unlocked with a crushed pill in a cup on top while it was out of view, then left medications unattended at a resident’s bedside after dropping a syringe. The resident had metabolic encephalopathy, bacterium, and G-tube status and was receiving multiple scheduled meds via G-tube.
Food Was Not Palatable or Attractive: Surveyors observed regular and alternate lunch items that were bland, mushy, and visually unappealing, including a turkey product with a spongey texture, overcooked peas, limp noodles, and a grainy meat patty. Several residents with serious dx such as malnutrition, DM, ESRD on dialysis, CHF, COPD, and pancreatitis said the meals were terrible, tasteless, and hard to eat, and one resident reported family had to bring food from outside because the facility meals were not edible.
Failure to Obtain Informed Consent for Psychotropic Medications: A resident with moderate cognitive impairment and no active psychiatric dx was started on alprazolam, bupropion, hydrocodone-acetaminophen, and zolpidem without any consent forms in the EMR. The DON said the ADON was responsible for obtaining medication consents, but the forms could not be found, and the facility policy required informed consent before psychotropic meds were initiated.
Call Light Not Kept Within Reach: A resident with moderate cognitive impairment, recent amputation, stroke history, and fall risk was observed in bed with her call light on the floor underneath her bed. She stated she had used the call light and did not know where it was, and said she did not feel safe because she could not reach it. Staff, including a CNA, an LVN, the DON, and the Administrator, stated that staff were responsible for keeping the call light within reach before leaving the room.
A facility failed to follow EBP for two residents with indwelling devices. An LPN inserted and collected urine from a resident with a foley catheter while wearing gloves but no gown, and another LPN accessed a resident’s CVC to flush and administer IV antibiotics while wearing gloves but no gown. Both residents had EBP signage, and the DON stated staff were expected to wear gowns and gloves for EBP-related care.
A resident with ESRD on peritoneal dialysis, prior possible peritonitis, stroke, diabetes, and heart failure was care planned for nightly PD with nursing interventions to monitor for infection and dialysis complications, but the facility did not ensure that PD supplies and a functioning cycler were available, resulting in missed treatments. The resident and CNA reported that the family performed PD hookups and the resident sometimes disconnected herself, while nursing staff did not monitor the dialysis process beyond basic vitals and site checks. The DON and RN stated that admission was contingent on self- or family-performed PD, that the facility had no emergency PD equipment, and that staff were not trained or authorized to connect, disconnect, or troubleshoot PD, despite facility PD training materials assigning nurses responsibility for clinical surveillance and recognition of peritonitis and fluid overload. The resident was later hospitalized with abdominal pain, nausea, vomiting, and suspected peritonitis after missed PD treatments and lack of supplies.
A nurse failed to secure and properly dispose of an IV antibiotic medication prescribed for a resident with a knee infection. The medication, which required refrigeration, was left unattended on a door handle in a resident hallway, exposed to sunlight and not locked away as required. Staff interviews confirmed the medication was not handled according to policy, and it was only destroyed after being discovered by another nurse.
Three residents with complex medical needs were not accurately coded in their MDS assessments for BiPAP/CPAP use and, in one case, a PICC line for IV therapy. Observations showed respiratory equipment was not cleaned or stored as ordered, and care plans did not consistently address these treatments. Staff interviews confirmed that MDS assessments were not completed accurately, and the facility's policy on assessment accuracy could not be reviewed.
Several residents requiring respiratory care did not receive services consistent with professional standards, as BiPAP/CPAP masks were improperly stored or not cleaned, and oxygen tubing was not dated or discarded as required. Staff interviews confirmed lapses in following protocols for cleaning, storage, and documentation of respiratory equipment, and care plans and medical records were found to be incomplete or inaccurate regarding respiratory support.
A resident with multiple risk factors for skin breakdown developed a Stage 3 pressure ulcer and several deep tissue injuries after staff failed to implement timely preventive care, properly use pressure-relieving devices, and communicate skin concerns. Inconsistent skin assessments, lack of wound care consultation, and improper use of offloading wedges contributed to the deficiency.
Several residents were not treated with dignity when one was left exposed in bed with her gown improperly closed, and three others with indwelling urinary catheters did not have privacy covers on their drainage bags. Staff were aware of the requirements for privacy and dignity but did not ensure these measures were in place, despite facility policies and training mandating such practices.
A resident with severe cognitive and physical impairments did not consistently receive scheduled bed baths and grooming, as evidenced by disheveled and matted hair and exposed clothing in photographs. Additionally, an LVN was observed standing while feeding the resident, contrary to facility policy and training, increasing the risk of choking. Documentation and family reports highlighted lapses in personal hygiene and feeding assistance, despite the resident's need for substantial staff support.
Several residents with indwelling urinary catheters did not have securement devices in place as required by care plans and physician orders, despite staff being aware of the policy and having received training. Observations and record reviews confirmed that catheter tubing was not anchored, and staff could not explain the omission, resulting in noncompliance with facility protocol.
Two residents in the facility did not receive wound care treatments as per physician orders, with multiple blanks on the TAR and MAR indicating missed treatments. Resident #1, with a history of cellulitis and diabetes, and Resident #4, with muscle wasting and diabetes, both had incomplete wound care documentation. Interviews with staff confirmed that blanks on the TAR meant treatments were not done, and there was a lack of documentation explaining these omissions.
A facility failed to provide necessary wound care for a resident with a stage 3 pressure ulcer, as a blank entry on the TAR indicated a missed treatment. Interviews with staff confirmed that the treatment was not performed, risking infection and delayed healing. The facility's policy requires accurate documentation of physician orders, which was not followed.
A facility failed to administer an albuterol inhaler to a resident with COPD and asthma as per physician orders, resulting in blanks on the MAR for two days. Staff interviews revealed inconsistencies in documenting medication administration, with some staff unsure of the implications of blanks on the MAR/TAR. The facility's policy required accurate transcription of physician orders, which was not followed, leading to a deficiency in providing necessary respiratory care.
The facility failed to properly store, label, and date food items in the kitchen, with missing temperature logs for refrigerators. Additionally, not all items on the steam table were temped, and the dishwasher thermometer was malfunctioning, risking foodborne illness and improper sanitization.
A facility failed to replace a resident's oxygen tubing weekly as ordered, risking respiratory compromise and infection. The resident, with conditions like COPD and a history of pneumonia, had tubing dated weeks old despite orders for weekly changes. Staff interviews revealed inconsistencies in practice and documentation, highlighting risks of infection and decreased oxygen levels.
A facility failed to regularly inspect bed frames and mattresses, resulting in a resident having an oversized bariatric mattress on a standard twin bed frame. This mismatch caused discomfort and potential safety hazards, as the mattress did not fit properly and slipped when the resident attempted to sit. Despite family concerns, the issue was not addressed until observed by surveyors, highlighting a lapse in maintenance and communication among staff.
A resident with multiple medical conditions did not receive prescribed pain medications before wound care, leading to increased pain during an ileostomy bag change. The nursing staff failed to verify and document the administration of pain medication, contrary to the facility's pain management policy. The resident exhibited signs of pain, and the DON acknowledged the risk of medication errors due to delayed documentation.
A resident with an ileostomy experienced skin excoriation and pain due to inadequate care and pain management. The resident's care plan was not followed, leading to improper ileostomy bag changes and lack of pain medication administration. Nursing staff failed to document and verify pain management, resulting in the resident enduring unnecessary pain during procedures.
A facility failed to follow prescribed enteral feeding orders for a resident, setting the water flush rate at 150 mL every 4 hours instead of the ordered 200 mL. The LVN responsible admitted to not checking updated orders, risking dehydration for the resident. Interviews with facility leadership highlighted expectations for staff to verify and follow orders, with the DON noting the LVN's previous non-compliance issues.
A medication cart was left unlocked and unattended by an LVN in a hallway, allowing potential unauthorized access to medications. The LVN was unable to maintain visual contact with the cart while attending to a resident, and an ADON moved the cart without realizing it was unlocked. Interviews confirmed awareness of the policy requiring carts to be locked when out of sight, and recent training had been conducted to reinforce this requirement.
A facility failed to maintain accurate medical records for a resident's PICC line care, lacking physician orders for dressing changes and management. The oversight occurred during the resident's readmission, with nursing staff assuming orders were in place. The ADON, responsible for monitoring such orders, was absent, contributing to the error. The facility's policy requires complete documentation of orders, but this lapse could delay care and treatment.
A resident with VRE and MRSA infections was put at risk due to RN H's failure to follow infection control protocols during ileostomy care. RN H did not perform hand hygiene or change soiled gloves, handled clean supplies with contaminated gloves, and improperly managed supplies in an isolation room. Interviews revealed RN H's nervousness and lack of experience contributed to these lapses, and documentation showed incomplete training records.
A facility failed to provide adequate pain management for three residents, leading to prolonged high pain levels and distress. Despite being prescribed pain medications, residents experienced delays and ineffective pain relief, with staff failing to notify physicians or properly assess pain levels. Interviews revealed inconsistencies in pain management practices, contributing to the deficiency.
The facility failed to ensure accurate administration of medications for a resident with severe cognitive impairment and multiple comorbidities. LVN A and MA B administered BiDil despite the resident's blood pressure being outside the physician-ordered parameters, without notifying the medical staff. The care plan did not include BiDil administration, and the facility's policy on vital sign documentation was not followed.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation, the walk-in refrigerator contained an opened box of lettuce with scattered lettuce outside the box and on the floor, an unlabeled and undated plastic container of potato salad, and 11 plastic containers of chocolate pudding that were also undated and unlabeled. The reach-in refrigerator contained a pitcher of lemonade and tea that were undated and unlabeled. The dry storage area also had food and supplies stored improperly, including a pack of 17 Styrofoam cups left unsealed on the floor, a 96-oz plastic jar of amber honey with a cracked lid that had leaked onto the floor, and an orange on the floor underneath the storage shelves. In interview, the Dietary Manager said she had worked at the facility only a few days and was responsible for ensuring food items in the refrigerators and dry storage area were sealed, labeled, dated, and stored correctly, but said she was new and did not have time to make corrective changes. The Administrator stated it was the Dietary Manager's responsibility to ensure foods were properly dated, labeled, sealed, and kept off the floor. The facility policy required opened and bulk items to be tightly covered, labeled, and dated, and required refrigerated foods to be tightly sealed and stored in approved containers.
Improper Garbage Receptacle Storage and Disposal
Penalty
Summary
The facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards. During an observation on 2-10-2026 at 8:25 AM, the facility’s only kitchen was observed with a large trash can containing trash and left open and unsealed, a smaller closed trash can next to the handwashing sink with an open box full of trash on top of it, and a third smaller trash can with the lid propped up while containing trash. During an observation on 2-10-2026 at 8:30 AM, the facility’s only outside trash dumpster area was observed to be full, with two sliding doors open and trash bags hanging outside the doors. Trash items were found on the ground around the dumpster, including used latex gloves, used to-go Styrofoam food containers, open boxes of trash, and trash bags leaking liquid onto the ground. Interviews with the Maintenance Director, Dietary Manager, and Administrator identified the Maintenance Director as responsible for the outside dumpster area and the Dietary Manager as responsible for keeping kitchen trash can lids on when not in use. The facility policy stated trash receptacles were to be kept clean and sanitary, with indoor trash cans kept covered when not in use and outdoor receptacles kept closed with no waste outside the receptacle.
Unlocked medication and treatment carts and unattended bedside medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and accessible only to authorized personnel when Nurse Treatment Cart B was observed unlocked and unattended in the corridor outside a resident room. The cart’s lock mechanism was out, indicating it was unlocked, and it contained over-the-counter wound care medications, a betadine solution, and prescription-strength medication. A CNA was nearby, and no residents were observed around the cart when it was found unattended. During interview, the ADON stated she was one of two nurses working on that hallway and said she did not know who left Nurse Treatment Cart B unlocked. She explained that the cart was used by nursing when the wound nurse was unavailable, that all nurses had keys and access to it, and that it needed to be locked when unattended. She also stated all nursing staff were responsible for making sure carts were locked and secured when not in use. A second nurse on the hallway also stated she did not know who left the wound cart open. The facility also failed to secure medications during administration to Resident #94. Resident #94 was admitted with metabolic encephalopathy, bacterium, and gastrostomy status, and had an active medication regimen including amiodarone, buspirone, metoprolol, midodrine, and sodium bicarbonate via G-tube. During observation, LVN G entered the resident’s room and left Med Cart A unlocked with a crushed pill in a medication cup on top of the cart while the cart was out of her view. After dropping a syringe on the floor, she removed her PPE and left all medications unattended at the resident’s bedside while she left the room to get a clean syringe. In interview, LVN G stated she was nervous and forgot to lock the cart and secure the medication, and acknowledged she was responsible for securing medications before walking away.
Food Was Not Palatable or Attractive
Penalty
Summary
The facility failed to ensure that regular diet meals were palatable and attractive for five residents who were reviewed for food and nutrition services. During observation of test trays on 02/11/26, surveyors found the regular lunch plate had thick slices of a turkey product with a spongey, slightly gelatinous texture, little turkey flavor, and a salty taste, along with green peas that appeared overcooked and noodles that were pale, bloated, limp, and very mushy. The alternate plate included a meat patty with brown gravy that fell apart in the mouth, had a rough, grainy texture, and did not resemble meat in texture or taste. The affected residents included individuals with significant medical and nutritional concerns. One resident had infection related to an infected knee surgery site, protein-calorie malnutrition, diabetes, heart disease, and a pacemaker, and his nutrition assessment noted intake between 0% and 25% of meals with a recommendation to liberalize the diet to promote intake and honor preferences. Another resident had sepsis, COPD with acute exacerbation, protein-calorie malnutrition, and diabetes, and was ordered a regular low-salt heart-healthy diet. Additional residents had metabolic encephalopathy with ESRD and dialysis, acute on chronic heart failure with respiratory failure and dialysis dependence, and acute pancreatitis with severe protein-calorie malnutrition, and all had BIMS scores of 15 indicating intact cognition. Resident interviews and observations showed repeated complaints that the food was bland, unappetizing, and difficult to eat. One resident said the food was terrible, had no taste, and made him feel gross, and another said the food was very bland and as bad as he had ever had. A resident was observed leaving almost an entire meal untouched and said the vegetables were boiled too long and the facility did not use seasonings or margarine for flavor. Another resident said he took one bite of breakfast because it was not edible and that his family had to bring food from outside so he would have something he could eat. The dietitian stated the regular lunch items were plain and that the turkey product matched the packaging but was not a true turkey item, and the Administrator and Dietary Manager acknowledged that food quality and palatability were their responsibility.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was informed of and participated in his treatment, including being informed in advance of the risks, benefits, and alternatives for proposed care. The deficiency involved Resident #101, a male admitted with pneumonia, chronic respiratory failure, kidney failure, and heart disease. His admission MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and a depression indicator score of 13. His face sheet showed no psychiatric diagnoses, and the record reflected no active psychiatric diagnoses or behavioral problems. Resident #101’s order summary showed orders for alprazolam for anxiety, bupropion for depression, hydrocodone-acetaminophen for severe pain, and zolpidem tartrate for insomnia. His care plans included monitoring for adverse effects related to hypnotic therapy, antidepressant medication, opioid medications, and antianxiety medication. Review of the electronic medical record found no consent forms for alprazolam, bupropion, hydrocodone-acetaminophen, or zolpidem before these medications were started. During interview, the DON stated she could not find the consent forms for Resident #101 and said the ADON was responsible for obtaining medication consents. She explained that consents were completed on admission or the next morning if the resident arrived at night, and reviewed in morning meetings or on Monday mornings after the weekend. The facility policy stated that psychotropic medication orders would be initiated only after the physician completed and returned an informed consent related to the drug, and that the drug order would include a start date on completion of the informed consent form.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure Resident #62 had a call light within reach. Resident #62 was a [AGE]-year-old female who re-admitted to the facility with diagnoses including encounter for orthopedic aftercare following surgical amputation, absence of the right leg above knee, sepsis, type 2 diabetes mellitus, and cerebral infarction. Her MDS showed a BIMS score of 11, indicating moderate impairment. Her care plan stated she was at risk for falls and directed staff to ensure her call light was within reach and to encourage her to use it for assistance as needed, with prompt response to all requests for assistance. During observation, Resident #62 was lying in bed in a tilted-up position with her call light on the floor underneath her bed. She stated she had used her call light and did not know where it was, and said she did not feel safe because she could not reach it. CNA A, LVN B, the DON, and the Administrator each stated that staff were responsible for ensuring the resident's call light remained within reach before leaving the room. The facility's call light policy stated that all staff members are expected to respond to call lights and that call lights will be answered in a timely manner.
Failure to Follow Enhanced Barrier Precautions During Device Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents who were on Enhanced Barrier Precautions (EBP). Resident #8 was an [AGE]-year-old female with diagnoses including metabolic encephalopathy, an unspecified open wound to the left hand, and sepsis. Her record showed an active order for an indwelling foley catheter and care plan interventions for EBP related to the foley catheter and IV therapy. During observation, the resident had EBP signage on her door, but there was no PPE cart outside the room. LVN E wore gloves while inserting the foley catheter and collecting urine for a UA, but did not wear a gown as required for EBP. Resident #81 was an [AGE]-year-old male with diagnoses including infection and inflammatory reaction due to an internal right knee, protein-calorie malnutrition, type 2 diabetes, heart disease, and a pacemaker. His record included orders for EBP related to IV access, a central venous catheter in the left chest, and IV cefazolin. During observation, EBP signage was present at the door, but there was no PPE cart outside the room. LVN D verified the resident and administered IV antibiotics through the central line while wearing gloves, but did not wear a gown before accessing the CVC. The DON stated that if a resident was on EBP, staff were to wear gloves and gowns while providing care, and that all nursing staff were responsible for following EBP. The facility’s in-service on Enhanced Barrier Precautions listed gown and glove use for high-contact resident care activities and device care, including central lines and urinary catheters. The facility policy also stated that staff were responsible for complying with isolation precautions and calling observed variances to policy to attention.
Failure to Ensure Safe Peritoneal Dialysis and Supply Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring peritoneal dialysis (PD) received dialysis services consistent with professional standards of practice. The resident was an adult female with end-stage renal disease, prior possible peritonitis, stroke, type 2 diabetes, and heart failure, who was admitted with an active need for PD from 6 p.m. to 6 a.m. Her care plan identified dialysis needs and directed staff to monitor the PD catheter site for redness or drainage, report cloudy effluent, inadequate drainage or inflow problems, sudden weight changes, shortness of breath, abdominal pain, fever, and signs of infection. The care plan also documented that PD would be completed independently by the resident or guest and that the resident would supply her own supplies. Despite this, the facility did not ensure that dialysis supplies, including a functioning cycler, were available on specific days, and the resident missed PD treatments on those days. The resident reported that she performed her own dialysis and that nursing staff did not monitor her during the dialysis process or check on her while it was occurring. She stated that earlier in the week she did not have the equipment needed to do her dialysis because the cycler she was using was broken and she was waiting for her family to bring supplies from home. She did not request supplies from the facility because her family usually brought enough supplies for about five days at a time. She acknowledged missing two or three days of dialysis in the past and stated that nurses took her vital signs, listened to her chest, and sent her for chest x-rays after she had missed days of dialysis, and that she later experienced vomiting and was sent to the hospital. CNA interview indicated that the family hooked the resident up to the dialysis machine and left the facility, and that if the family was late returning, the resident disconnected herself from the machine. The DON stated that admission was contingent on the resident or family performing all aspects of PD independently and that facility nurses were responsible only for monitoring, which she described as reminding the resident to connect and disconnect from the machine. She reported that the facility did not have emergency PD equipment on site, that the resident missed two days of dialysis during a winter storm because the family did not bring supplies and the cycler was broken, and that the resident had stated she was fine with missing those treatments. The DON also stated that when a treatment was missed, the PCP was to be notified, and that the PCP was notified after missed treatments and the resident was assessed and sent for x-rays. RN staff reported they were not trained to connect, monitor, or disconnect the PD machine, and that their monitoring consisted of checking the catheter site for redness or drainage, taking vital signs, and confirming that the resident connected and disconnected herself, with the resident entering her own dialysis data into the machine. The facility’s PD inservice materials and an undated admission acknowledgment form showed that the facility did not provide staff-assisted PD, placed responsibility for supplies and equipment on the resident/family, and limited staff responsibilities to general clinical surveillance and vital signs, while prohibiting staff from performing PD connections or troubleshooting PD equipment. The resident was later admitted to the hospital with abdominal pain, nausea, vomiting, and suspected peritonitis, and the PCP stated that the resident not having supplies to properly do dialysis placed her at risk of becoming septic.
Failure to Secure and Properly Dispose of IV Medication
Penalty
Summary
A deficiency occurred when a nurse failed to properly store and secure an intravenous (IV) antibiotic medication prescribed for a male resident with a history of infection and inflammatory reaction due to an internal knee prosthesis. The resident was receiving IV medications, including vancomycin and ceftriaxone, for a knee infection and required enhanced barrier precautions and regular monitoring of his PICC line and dressing. The resident was cognitively intact and required varying levels of assistance with activities of daily living. On the day of the survey, the resident's PICC line medication, labeled as requiring refrigeration, was found left unattended on the exit door handle at the end of the resident hall, exposed to sunlight. The medication was not secured in a locked compartment as required by state and federal regulations. The nurse responsible for administering the medication admitted to leaving it on the door handle with the intention of destroying it later but forgot about it until notified by another staff member. The medication was subsequently destroyed by pouring it down the toilet after being retrieved by another nurse. Interviews with facility staff, including the LVN, MDS nurse, ADON, DON, and CNA, confirmed that the medication was not stored or discarded according to facility policy and regulatory requirements. Staff acknowledged that the medication should have been immediately secured and destroyed in the designated medication room container. The incident was recognized as a failure to follow proper medication storage and destruction protocols, which could have allowed unauthorized access to the medication.
Failure to Accurately Code MDS Assessments for Respiratory and IV Treatments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status and treatments of three residents. Specifically, the MDS assessments for these residents did not properly code for the use of BiPAP/CPAP treatments, and in one case, did not code for a PICC line as ordered by the physician. Observations revealed that BiPAP/CPAP masks were not stored or cleaned according to physician orders, with masks found on the floor, on nightstands, or in drawers unbagged, and residents reported that staff had not cleaned or bagged their equipment. The MDS coordinator stated that coding for a non-invasive mechanical ventilator was considered sufficient, but specific sections for BiPAP and CPAP were left blank, and the PICC line was not documented as required. The residents involved had significant medical histories, including chronic heart failure, obstructive sleep apnea, COPD, osteomyelitis, sepsis, asthma, and chronic respiratory failure. All three residents were cognitively intact and required varying levels of assistance with activities of daily living. Physician orders and care plans indicated the need for BiPAP/CPAP treatments and, in one case, a PICC line for IV antibiotic therapy. However, these treatments were not consistently documented in the MDS assessments, and care plans did not always address the respiratory equipment or IV therapy as required. Interviews with facility staff, including the MDS coordinator and DON, confirmed that the responsibility for accurate and timely completion of MDS assessments rested with the MDS coordinator, with RN review for accuracy. Despite this, the assessments were not completed accurately to reflect the residents' care and treatments. The facility's policy for conducting accurate assessments was requested but could not be reviewed due to technical issues with the electronic copies provided.
Deficient Respiratory Care Practices and Equipment Handling
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such care, as evidenced by multiple deficiencies in the handling, cleaning, and storage of respiratory equipment. Observations revealed that several residents' BiPAP/CPAP masks were not stored according to facility protocol for sanitation. For example, one resident's mask was found on the floor, while another's was left unbagged on a nightstand. Additionally, a resident reported that their mask had not been cleaned since admission. These actions were inconsistent with both physician orders and facility policy, which require daily cleaning and proper storage of respiratory devices in clean, dated bags when not in use. Further deficiencies were noted in the management of oxygen therapy equipment. One resident was observed wearing a nasal cannula (NC) with tubing that was not dated, and an additional, used NC was found on the resident's wheelchair seat. The resident was unable to recall when the tubing was last changed. Facility policy and physician orders specified that oxygen tubing should be changed weekly and dated, and that used tubing should be discarded immediately to maintain a clean clinical environment. Interviews with staff confirmed that these procedures were not consistently followed, and that lapses in discarding old equipment and dating new tubing had occurred. Record reviews for the affected residents showed that care plans and medical orders addressed the need for respiratory support, including BiPAP/CPAP use and oxygen therapy. However, documentation was incomplete or inaccurate in some cases, with missing or improperly coded information regarding the type of respiratory support provided. Staff interviews further confirmed that there was a lack of adherence to established protocols for cleaning, storage, and documentation of respiratory equipment, which could compromise the quality of care provided to residents requiring respiratory support.
Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and preventive care for a resident at risk for pressure ulcers, resulting in the development of multiple pressure injuries. Upon admission, the resident had several risk factors, including diabetes, stroke, hemiplegia, malnutrition, and severe cognitive impairment, and was dependent on staff for mobility and self-care. Initial assessments documented redness to the heels, groin, buttocks, and eschar to the left big toe, but the wound care team was not notified, and preventive interventions such as pressure-relieving devices were not implemented in a timely manner. The care plan included interventions like barrier cream, frequent repositioning, and skin monitoring, but there was a lack of consistent follow-through and communication among staff regarding these interventions. Over the course of the resident's stay, staff failed to monitor and respond to early signs of pressure injury, particularly on the heels and sacrum. Weekly skin assessments inconsistently documented skin issues, and the wound care nurse did not recognize or escalate concerns about developing wounds. The wound care nurse also demonstrated a lack of knowledge regarding wound staging and did not consult the wound medical doctor when significant skin changes were identified. Observations and interviews revealed that pressure offloading devices, such as wedges and heel protectors, were not properly placed or used, and staff were unclear about their correct application and purpose. Additionally, there was inadequate documentation and monitoring of repositioning and offloading interventions. As a result of these failures, the resident developed a Stage 3 pressure ulcer on the sacrum and multiple deep tissue injuries to the heels and toes, which were not present on admission. The facility's own policies and professional standards of practice for pressure ulcer prevention, including timely assessment, use of pressure-relieving devices, and appropriate staff communication, were not followed. These deficiencies were identified through observations, interviews, and record reviews, and placed residents at risk for new or worsening pressure ulcers.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity and respect for four residents by not ensuring proper coverage of their bodies and by not providing privacy covers for indwelling urinary catheter drainage bags. One resident, a female with severe cognitive impairment, hemiplegia, and total dependence on staff for activities of daily living, was observed in photographs provided by her family to be lying in bed with her gown pulled down, exposing her right shoulder and upper chest. Staff interviews confirmed that the resident required total care and that such exposure would be considered a violation of resident rights and dignity. The staff stated that rounds were performed every two hours, but they were unaware of the exposure until shown the photographs by the surveyor. Additionally, three other residents with indwelling urinary catheters were observed without privacy covers on their catheter drainage bags. Observations revealed that the catheter bags were visible and not covered as required by facility policy and standard practice. Staff interviews confirmed knowledge of the requirement for privacy covers, but they could not explain why the covers were not in place at the time of observation. The care plans for these residents did not consistently include interventions to ensure catheter bag privacy, and the staff responsible for catheter care acknowledged their responsibility but failed to implement the required measures. Facility policy reviews indicated that all staff were required to attend annual in-service training on resident rights and abuse prevention, and that catheter drainage bags should be covered with dignity covers. Despite these policies and training, the observed failures resulted in residents being exposed or having their catheter bags visible, which could compromise their dignity and psychosocial well-being. The surveyors did not receive a copy of the facility's Resident Rights Policy during their visit.
Failure to Provide Consistent ADL Care and Proper Feeding Technique
Penalty
Summary
The facility failed to provide consistent care and assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, who had a history of severe cognitive impairment, stroke with resulting hemiplegia and hemiparesis, aphasia, dysphagia, end-stage renal disease, and dependence on dialysis, required substantial to maximal assistance with all ADLs, including bathing, grooming, oral hygiene, dressing, and feeding. According to the care plan and ADL schedule, the resident was to receive bed baths three times per week and assistance with grooming and hygiene. However, documentation and family interviews indicated that bed baths and grooming were not provided consistently according to the schedule, and the resident was observed with disheveled and matted hair on multiple occasions. Photographs provided by the family showed the resident with exposed upper chest and shoulder, and her hair in poor condition, suggesting lapses in personal care and dignity. Additionally, the report documents that a Licensed Vocational Nurse (LVN) was observed standing while feeding the resident, contrary to facility policy and in-service training, which require staff to be seated while feeding residents to reduce the risk of choking and aspiration. The LVN acknowledged having received training on proper feeding techniques but admitted to standing while feeding the resident on at least one occasion, as confirmed by video footage provided by the family. Interviews with staff and administration confirmed that the expectation is for staff to sit while feeding residents, and that standing while feeding poses a risk to resident safety. The facility's own records, including shower sheets and grievance logs, corroborated the family's concerns about inconsistent ADL care. The resident's family filed a grievance on the day of discharge, citing inadequate assistance with personal hygiene and grooming. Staff interviews revealed that while some ADL care was documented, there were discrepancies between staff accounts and the family's observations, particularly regarding the resident's grooming and the manner in which feeding assistance was provided. The facility's policies require individualized care based on comprehensive assessment, but the observed and reported deficiencies indicate that these standards were not consistently met for this resident.
Failure to Secure Indwelling Urinary Catheters as Ordered
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, specifically by not ensuring the use of catheter securement devices (straps) to prevent pulling or tugging of the catheter tubing. Observations on multiple residents revealed that the catheter tubing was not secured with a strap, as required by facility policy and physician orders. For example, one resident was observed in bed with the catheter tubing lying across the leg and no securement device in place, while another resident had the catheter tubing hanging through pajama pants and attached to a drainage bag on a walker, also without a securement device. Record reviews showed that care plans and physician orders for these residents included instructions for catheter care, such as anchoring the tubing with a strap and checking skin integrity. However, these interventions were not consistently implemented. In one case, the care plan did not include specific interventions for positioning the catheter bag and tubing or ensuring a securement device was in place. Additionally, medication administration records did not always reflect that catheter care orders were followed as written. Interviews with staff confirmed that they were aware of the need for catheter securement devices and privacy covers for drainage bags, but could not explain why these were not in place for the affected residents. Staff described their training and responsibilities regarding catheter care, but acknowledged the absence of securement devices during the survey. The facility's own policy required the use of securement devices to prevent movement and reduce infection risk, but this was not adhered to for the residents reviewed.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and the comprehensive person-centered care plan for two residents. Resident #1, a male with a history of cellulitis, metabolic encephalopathy, and type 2 diabetes mellitus, did not receive wound care treatments as per physician orders. The treatment records for Resident #1 showed multiple blanks on the Treatment Administration Record (TAR) and Medication Administration Record (MAR), indicating that the prescribed treatments, including the application of betadine and wound dressings, were not consistently administered. The progress notes did not provide explanations for these omissions. Resident #4, a male with muscle wasting, traumatic ischemia, and type 2 diabetes mellitus, also did not receive wound care as ordered. The TAR for Resident #4 showed a blank entry for a scheduled wound dressing change, and the progress notes did not document any reason for the missed treatment. Interviews with the Wound Care Nurse and other staff revealed that blanks on the TAR typically indicated that treatments were not performed, and there was a lack of documentation to justify these omissions. The Director of Nursing (DON) and other staff members confirmed that the absence of signatures on the MAR and TAR meant treatments were not completed. The facility's policy required that all physician orders be documented and transcribed accurately, and any unclear orders be clarified before implementation. However, the failure to adhere to these protocols resulted in residents not receiving necessary wound care, potentially impacting their health and recovery.
Failure to Document and Perform Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as evidenced by the lack of a documented wound dressing change for a resident with a stage 3 pressure ulcer on the right buttock. The resident, an elderly female with a history of osteomyelitis, sepsis, and muscle weakness, was admitted to the facility with specific physician orders for daily wound care. However, a review of the Treatment Administration Record (TAR) revealed a blank entry on a specific date, indicating that the treatment was not completed as ordered. Interviews with the wound care nurse, RN, LVN, and the Director of Nursing (DON) confirmed that a blank on the TAR signifies that the treatment was not performed. The wound care nurse and RN emphasized the importance of signing off on the TAR to ensure treatments are administered and documented. The DON and Administrator acknowledged the risk of infection and delayed healing due to the failure to document and perform the treatment. The facility's policy requires that all physician orders be promptly and accurately transcribed and documented, which was not adhered to in this instance.
Failure to Administer Albuterol Inhaler as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care to a resident, specifically in administering an albuterol inhaler as per physician orders. The resident, who had been diagnosed with chronic obstructive pulmonary disease (COPD), asthma, and heart failure, did not receive the prescribed albuterol inhaler on two consecutive days. The medication administration record (MAR) for these days contained blanks, indicating that the medication was not administered, and there was no documentation in the progress notes explaining the omission. Interviews with facility staff revealed a lack of clarity and consistency in documenting medication administration. The Director of Nursing (DON) acknowledged that a blank on the MAR or treatment administration record (TAR) meant the medication was either not administered or not signed off. Staff members, including a wound care nurse and registered nurse, emphasized the importance of signing off on the MAR/TAR to confirm that care was provided. However, one licensed vocational nurse (LVN) was unsure of the implications of a blank on the MAR/TAR. The facility's policy required prompt and accurate transcription of physician orders, but this was not adhered to in this case, leading to a failure in providing the necessary respiratory care to the resident.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed multiple instances of improperly stored food in the facility's kitchen, including items in the refrigerator and freezer that were not labeled or dated. For example, a medium stainless steel pan of brown gravy and a small plastic container labeled grilled chicken were found without proper dating or covering. Additionally, temperature logs for the reach-in refrigerators were missing entries for several days, indicating a lack of consistent monitoring. Further deficiencies were noted in the handling of food temperatures on the steam table. During an observation, a staff member failed to take the temperature of all items on the steam table, such as white gravy and beef patties, because they were not listed on her sheet. The Dietary Manager confirmed that all items should be temped before serving. This oversight could lead to serving food at unsafe temperatures, posing a risk of foodborne illness to residents. The facility also failed to ensure the proper functioning of the dishwasher thermometer. A dietary aide admitted to not knowing how to take the temperature of the dish machine and simply copied previous entries on the temperature log. When the Dietary Manager checked the dishwasher, it was found to be reading incorrect temperatures, which could result in dishes not being properly sanitized. The Maintenance Director was unaware of the issue until it was brought to his attention, despite a recent repair to the dishwasher's temperature module.
Failure to Replace Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not replacing the resident's oxygen tubing weekly as per physician's orders. The resident, a male with moderately impaired cognition, was receiving continuous oxygen therapy due to conditions including anemia, chronic obstructive pulmonary disease, and a history of lumbar spinal fusion surgery. The resident had been hospitalized for hypoxia and sepsis secondary to pneumonia before being transferred to the facility for skilled nursing care. Despite orders to change the oxygen tubing every Sunday night shift, observations revealed that the tubing and water bottle were not changed as required, with dates on the equipment indicating they had not been replaced since 10/20/24. Interviews with facility staff, including the DON and LVNs, confirmed that the oxygen tubing should be changed weekly and as needed to prevent infection and ensure proper oxygen delivery. However, discrepancies were noted in the documentation and actual practice, as the MAR indicated the tubing was changed on specific dates, but observations contradicted these records. Staff members expressed surprise upon learning of the outdated tubing and acknowledged the risks associated with not changing the equipment, such as infection and decreased oxygen saturation levels. The facility's policy on O2 hygiene also emphasized the importance of changing tubing in accordance with physician orders to prevent infection.
Failure to Inspect and Maintain Proper Bed Equipment
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment hazards for a resident. Specifically, the facility did not identify that a resident's twin-sized bed had an oversized bariatric mattress, which did not fit properly within the bed frame. This oversight was discovered during an observation and interview, where it was noted that the mattress had a large depression causing discomfort and pain to the resident, and it slipped when the resident attempted to sit down. The resident, who was cognitively intact but had several medical conditions including repeated falls and muscle weakness, was unable to rest properly due to the ill-fitting mattress. Despite family members raising concerns about the mattress size to nursing staff, the issue was not addressed until it was observed by surveyors. The facility's maintenance and housekeeping procedures failed to identify and rectify the mismatch during room preparation and regular maintenance checks. Interviews with various staff members, including CNAs, the ADON, and the Maintenance Director, revealed a lack of communication and follow-through in addressing the mattress issue. Staff members acknowledged the risks associated with having a bariatric mattress on a standard twin bed frame, such as potential falls and discomfort, but the problem persisted until it was brought to the attention of the facility's administration during the survey.
Inadequate Pain Management for Resident During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident requiring such services, as observed during a survey. The resident, a male with multiple medical conditions including an abscess of the liver, Type 2 diabetes, Parkinsonism, and a non-traumatic perforation of the intestine, was not administered prescribed pain medications, Acetaminophen and Tramadol, before undergoing wound care. This oversight was noted despite the resident's care plan, which included interventions for pain management and wound care, indicating a need for scheduled pain medication evaluation and administration. On the day of the observation, the resident was found to be in pain during an ileostomy bag change, a procedure known to cause discomfort due to skin excoriation. The resident expressed uncertainty about receiving pain medication prior to the procedure, and the attending nurse, RN H, did not verify the administration of pain medication before proceeding with the wound care. The resident exhibited signs of pain, such as moaning and grimacing, during the procedure, which was not alleviated by the use of a handheld fan as suggested by the nurse. Interviews with the nursing staff revealed a lack of documentation and verification regarding the administration of pain medication. RN G admitted to not documenting the administration of Tylenol and was unaware of the last administration time of Tramadol. The Director of Nursing (DON) acknowledged the risk of medication errors due to delayed documentation and emphasized the importance of pain assessment and management. The facility's policy on pain management highlighted the need for optimal pain assessment and management, which was not adhered to in this instance.
Inadequate Ileostomy Care and Pain Management
Penalty
Summary
The facility failed to provide appropriate ileostomy care for a resident, leading to skin excoriation around the stoma site and stool leakage. The resident, a male with multiple medical conditions including Parkinsonism, diabetes, and a history of intestinal perforation, had an ileostomy that required regular care. The care plan for the resident included interventions to maintain skin integrity and manage pain, but these were not adequately followed. During an observation, it was noted that the resident's skin was bright red and raw around the ileostomy site, indicating improper care. The resident experienced significant pain during the ileostomy bag change, and it was revealed that pain medication was not administered as required before the procedure. The nurse responsible for the care did not verify the administration of pain medication, leading to the resident enduring unnecessary pain. Interviews with the nursing staff revealed a lack of documentation and communication regarding pain management. The nurse believed pain medication had been administered, but there was no documentation to confirm this. The Director of Nursing acknowledged the risk of medication errors due to delayed documentation and emphasized the importance of pain assessments. The facility's policy on pain management was not adhered to, resulting in the resident experiencing increased pain during care.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via enteral feeding received the appropriate treatment and services according to professional standards. Specifically, the facility did not adhere to the prescribed water flush rate for the resident's feeding tube. The resident, a male with multiple diagnoses including encephalopathy, gastrostomy status, and adult failure to thrive, was observed with a water flush rate set at 150 mL every 4 hours instead of the ordered 200 mL every 4 hours. This discrepancy was noted during an observation and interview with an LVN, who admitted to not checking the updated orders due to familiarity with the resident's previous regimen. The LVN acknowledged the oversight, stating that the physician had changed the order the day before, and failing to adjust the water flush rate could lead to dehydration. Interviews with the ADON and DON revealed that it was expected for nursing staff to verify and follow orders as prescribed, and failure to do so could delay care. The DON mentioned that the LVN had previous non-compliance issues and would be terminated. The facility's policy on physician orders emphasized the importance of accurately transcribing and following orders, highlighting the procedural lapse in this case.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation on A hallway, it was noted that LVN C left a medication cart unlocked and unattended while attending to a resident in their room. The medication cart was placed in the doorway, but LVN C was unable to maintain visual contact with it while she was in the resident's bathroom and at the bedside, reconnecting a feeding tube. This oversight was further compounded when ADON B moved the unlocked cart to retrieve a dropped hand sanitizer bottle, without realizing it was unlocked. Interviews with LVN C revealed that she was aware of the requirement to lock the medication cart when it was out of sight but failed to do so. She acknowledged the potential risk of residents gaining unauthorized access to medications, which could be harmful. ADON B also admitted to not checking if the cart was locked when she moved it and emphasized the importance of ensuring medication carts are secured to prevent unauthorized access to medications, including over-the-counter drugs. The DON and ADM both reiterated the facility's policy that medication carts must be locked when not in use and out of sight. They confirmed that recent in-service training had been conducted to reinforce this policy, and staff were expected to adhere to it. The facility's policy on medication storage clearly states that medication carts should be locked when not attended by authorized personnel, highlighting the importance of maintaining security and safety in medication management.
Deficiency in Maintaining Accurate Medical Records for PICC Line Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding physician orders for PICC line dressing and care. The resident, a male with multiple complex medical conditions including liver abscess, Type 2 diabetes, and Parkinsonism, was readmitted to the facility without proper documentation of PICC line management orders. This oversight was identified during a review of the resident's records, which did not include necessary orders for PICC line dressing changes and IV management, despite the resident receiving IV medications for an infection. Interviews with nursing staff revealed that the omission of PICC line orders occurred during the resident's readmission process. RN G, who readmitted the resident, assumed that all necessary orders were in place and did not verify or input the PICC line orders. The Assistant Director of Nursing (ADON) was responsible for monitoring such orders but was not present, contributing to the oversight. The Director of Nursing (DON) acknowledged the error and emphasized the importance of checking orders before procedures to prevent missing critical care steps. The facility's policy on physician orders requires that orders be documented completely and transcribed accurately by nursing staff. However, the failure to obtain and document PICC line orders for the resident led to a deficiency in care, as the necessary procedures for PICC line maintenance were not followed. This lapse in documentation and order management could potentially delay care and treatment for residents, as noted by the facility's administration.
Infection Control Lapses During Ileostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN H during the care of a resident with multiple complex medical conditions, including VRE and MRSA infections. During an observation, RN H did not perform hand hygiene or change soiled gloves while changing the resident's ileostomy bag. This oversight occurred despite the resident being on contact isolation, which required strict adherence to infection control protocols to prevent the spread of infection. RN H gathered supplies for the procedure but left them unattended on a treatment cart in the hallway, which was against the facility's infection control policy. Upon entering the resident's room, RN H did not clean the bedside table or remove the resident's drinks, which posed a risk of contamination. Throughout the procedure, RN H used soiled gloves to handle clean supplies and apply medication, further compromising the sterile field and increasing the risk of infection transmission. Interviews with the ADON and DON revealed that RN H was aware of the correct procedures but failed to follow them due to nervousness and lack of experience with ileostomy care. The facility's infection control policies were not adhered to, as evidenced by RN H's actions and the lack of documentation of her completion of relevant in-service training. The DON and ADON acknowledged the risk of contamination and infection spread due to these lapses in protocol.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to a deficiency in care. Resident #1, a cognitively intact female with multiple fractures and pain due to orthopedic devices, did not receive her prescribed oxycodone in a timely manner upon admission. Despite her complaints of severe pain, she was only given acetaminophen initially, and her pain levels remained high for several days without appropriate intervention or physician notification. Resident #2, also cognitively intact, suffered from high pain levels due to fractures and other conditions. Despite being prescribed tramadol and oxycodone, her pain levels remained elevated, and she reported feeling neglected by the nursing staff. She experienced delays in receiving pain medication and was not effectively monitored or assessed for pain relief, leading to increased distress and depression. Resident #3, with a history of shoulder dislocation and other painful conditions, experienced persistent high pain levels despite receiving various pain medications. The facility's change in pharmacy contributed to delays in medication administration, and staff failed to notify physicians about the ineffectiveness of the pain management plan. Interviews with staff revealed inconsistencies in pain assessment and management practices, contributing to the residents' prolonged suffering.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that assured accurate administration of medications for a resident with severe cognitive impairment and multiple comorbidities, including heart failure and kidney failure. Licensed Vocational Nurse (LVN) A and Medication Aide (MA) B did not follow physician orders when administering the heart medication BiDil on several occasions, despite the resident's blood pressure being outside the physician-ordered parameters. This failure was not documented as a medication administration record (MAR) error, and the medical staff was not notified of the deviations from the prescribed parameters. The resident's care plan did not include the administration of BiDil, and the electronic MAR and vitals record showed that the medication was administered even when the resident's blood pressure readings were outside the specified parameters. Interviews with the medical staff, including the nurse practitioner (NP) and the medical doctor (MD), revealed that they were not informed about the resident's blood pressure being outside the parameters and the subsequent administration of BiDil. Both LVN A and MA B admitted to potentially making mistakes in documenting the administration of the medication. The facility's policy required vital signs to be taken and documented before administering medications with specific parameters. The Regional Nurse confirmed that the staff should have checked the resident's blood pressure and notified the MD if it was outside the parameters. The failure to follow these procedures could place residents at risk of not receiving the therapeutic benefits of their medications, potentially leading to harm or a decline in health.
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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) |
|---|---|---|---|---|
| Wedgewood Nursing Home | 0.8 mi | ★★★★★ | 16 | 0 |
| Cityview Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 12 | 0 |
| Garden Terrace Healthcare Center Of Fort Worth | 1.1 mi | ★★★★★ | 7 | 0 |
| Ft. Worth Southwest Nursing Center | 1.3 mi | ★★★★★ | 6 | 0 |
| Avir At Fort Worth | 1.5 mi | ★★★★★ | 6 | 2 |
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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.