Fort Worth Wellness & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Resident #33, #42, and #83) reviewed for pain management. 1. The facility failed to provide effective pain medication for Resident #33 who admitted to the facility on [DATE] and received Hydrocodone-Acetaminophen 1 oral tablet 325 mg. per order, on all three shifts, for 7-15-2025 and 7-16-2025. Resident #33's pain levels remained high without physician notification or effective intervention. 2. The facility failed to provide effective pain medication for Resident #83 who re-admitted to the facility on [DATE] and received Acetaminophen-Codeine 1 300-30 mg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly. 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest by failing to ensure garbage was kept off the ground, surrounding the facilities two outside trash dumpsters, and failed to keep the facility's grease trap dumpster closed. These failures could place residents at risk of contracting disease by attracting pest and disease carrying rodents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #45) of one resident reviewed for resident rights. The facility failed to ensure CNA K was sitting down while feeding Resident #45 on 07/15/25. This deficient practice could place residents at risk of choking.

Inspectors wroteBased on interview and record review the facility failed to ensure that resident who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #67) reviews for dialysis documentation. The facility failed to ensure Nurses documented ongoing assessments of Resident #67's condition and monitoring complications before and after dialysis treatments received at a certified dialysis facility. This deficient practice could place residents at risk of complications from dialysis due to the lack of documentation between the facility and dialysis center in the event of a medical event.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #70) reviewed for infection control. CNA A failed to put on Personal Protective Equipment (PPE) while providing toileting care for Resident #70, who was on Enhanced Barrier Precaution (EBP). This deficient practice could place residents at risk of transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 4 halls reviewed (Hall 400) for environment. The facility failed to maintain Hall 400 in a safe and sanitary condition free from air conditioning condensation leaks from the ceiling onto the hallway floor. This failure could place residents at risk for injury and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one of one resident (Resident #25) room and in two public areas reviewed for pest control. The facility failed to ensure the facility was free of roaches in common areas and the dining room. The facility failed to ensure the facility was free of flies in Resident #25 room. This failure could place residents at risk of living in an unsanitary environment.

Inspectors wroteBased on interview and record review the facility failed to maintain privacy of medical records for one (Resident #2) of four residents reviewed for privacy of medical records. The facility failed to ensure the privacy of Resident #2's medical records was protected when RN A sent Resident #2's discharge summary (discharged [DATE]) and orders home with Resident #1 and Resident#1's family when Resident #1 was discharged on [DATE]. The deficient practice was identified as past noncompliance (PNC). The facility provided sufficient evidence that the alleged violation was investigated, corrected, no further incidents of unauthorized PHI sharing had occurred, and the facility was in substantial compliance prior to surveyor entrance on [DATE]. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #28, Resident #2, Resident #18, Resident #47, and Resident #60) of twelve residents observed for infection control. 1. The facility failed to ensure that CNA C and CNA D changed their gloves, perform hand hygiene, and perform proper direction of wiping while providing incontinent care to Resident #28. 2. The facility failed to ensure MA B sanitized the blood pressure cuff between Resident #2, Resident #18, Resident #47, and Resident #60. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for one (hallway 100) of four hallways, one of one dining areas, and one of one kitchen observed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of gnats and flies in a hallway, kitchen, and dining room. This could place residents at risk for an unsanitary environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean, comfortable environment and maintenance services for 1 (Resident #131) of 24 residents reviewed for clean and comfortable environment. The facility failed to maintain the flooring, covered vent and personal box fan in Resident #131's room. Floor tiles were broken, the vent cover was bent exposing a hole in the wall and the box fan was bent exposing the rotating fan blades. These failures could place the resident at risk for injury, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one(Resident #73) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #73's nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 14 reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (Residents #40, #55, and #58) of 24 residents reviewed for hygiene. The facility failed to bathe and groom Residents #40, #55, and #58 on a consistent basis. This failure placed all residents at risk of discomfort and developing skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident for two (Residents #41 and #186) of two residents reviewed for activities of daily living. The facility failed to assess Resident #41's and Resident #186's need for communication assistance to effectively communicate with staff. This failure could put residents at risk of having a loss of dignity and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for four (Residents #29, #40, # 56, and #75) of five residents reviewed for accurate documentation. The facility failed to ensure documentation of cares provided by the CNAs was complete and accurate for Residents #29, #40, #56, and #75. This failure placed residents at risk of not receiving the proper level of care and services needed to maintain their health status.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident had a right to be treated with respect and dignity regarding personal possessions, for one (Resident #30) of six residents reviewed for dignity issues. The facility violated Resident #30's rights by taking possession of her personal cell phone. Although this was initially done with consent, the facility failed to return the phone when Resident #30 requested it back. This failure could place all residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #55) of four residents reviewed for wound care. The facility failed to ensure that Resident #55's pressure ulcer dressing was replaced after being removed during ADL care. This failure placed the resident at risk of developing an infection in her wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer sufficient fluid intake to maintain proper hydration and health for 1 (Resident #68) of eighteen residents reviewed for hydration, in that: The facility failed provide/offer any means of hydration in between breakfast and lunch meals between 04/18/23-04/20/23 for Resident #68. This deficient practice placed residents at risk of dehydration, dry skin, Urinary Tract Infection's, and a decreased quality of life.