Ft Worth Southwest Nursing Center

Inspectors wroteBased on interview, observation and record review, the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 1 facility reviewed for storage. The facility failed to secure 10- 1 oz Zinc Oxide Ointment tubes observed on three linen cart pockets and 2- 1oz Zinc Oxide Ointment in a resident open top-drawer. This failure could place residents at risk of unauthorized access to over-the-counter drug or prescription.

Inspectors wroteBased on interview, observation, and record revie, the facility failed to provide a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 (Resident #1) of 5 residents reviewed for resident rights. The facility failed to provide a space free of severe hoarding of various items that left a narrow walkway of approximately 1 foot wide from Resident #1 door to bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care for 3 of 6 residents (Resident #2, Resident #3, and Resident #76) reviewed for Comprehensive Care Plan. The facility failed to ensure Resident #2, Resident #3, and Resident #76 and/or the resident's representative were invited and given the opportunity to participate in the resident's care plan meeting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. The facility failed to ensure the handwashing sinks #1 and #2 garbage receptacle contained only paper towels. The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents. The facility failed to ensure to discard spoiled items stored in the walk-in refrigerator. These failures could place residents at risk for food-borne illness, cross contamination, and infection. During an observation of the #1 handwashing sink's garbage receptacle on 05/06/2026 at 8:56 a.m., the following was revealed: [...]

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 catheter care for 3 of 6 residents (Resident #1, Resident #14, and Resident #122) reviewed for infection control. Resident #14's catheter bag was touching his fall mat. Resident #1 and Resident #122's catheter bags hung under their wheelchairs and touched the floor in the physical therapy room. This failure could place residents at risk for infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident and/or resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 (Resident #32 and Resident #139) of 6 residents reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #32 and Resident #139. The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #32 and Resident #139. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free of accident hazards for 1 of 6 (Resident #72) residents reviewed for accidents hazards and supervision. The facility failed to ensure Resident #72 did not obtain electronic cigarettes in her room. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to adhere to the federal requirements regarding residents' rights. The facility failed ensure a safe and decent living environment for two (Resident #2 and Resident #3's rooms) of five rooms reviewed for decent living environment. 1. The facility failed to ensure Resident #2's room was free of dirt, debris, and sticky floors on 10/10/25.2. The facility failed to ensure Resident #3's broken window was repaired. These failures could place residents at risk or diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of five (Resident #1 Room) resident rooms reviewed for pharmacy services. The facility failed to ensure a tube of Zinc Oxide Ointment and a bottle of Antiseptic Skin Cleanser were not left in Resident #1's room. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #1) of 5 residents records reviewed for treatment documentation. 1. The facility failed to document timely when Resident #1 refused to leave the courtyard area of the facility until 1:00 AM on 10/08/25. This failure could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 3 residents reviewed for accident hazards/devices. The facility failed to ensure CNA A and CNA B used the required assistive device (gait belt) to transfer Resident# 1 to prevent accidents. This failure could place residents at risk of avoidable falls, injuries, and reduced safety during transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure drugs and biologicals were secured properly in 1 (400 hall medication cart) of 6 Medication carts reviewed for drug storage. The medication cart on 400 hall was unlocked and no staff in view of the cart. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for three (Residents #27, #99, and #107) of five residents and all 29 residents in the 100 Hallway reviewed for safe, clean, homelike environment. 1. The facility failed to ensure the ceiling A/C vents for Resident #27, #99 and #107's rooms were clean and not dusty on 02/03/2025. These failures could affect residents that reside on the 100 Hallway and place them at risk for not having a safe and sanitary homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #78) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #78 received the correct dosage of morphine 15 mg as ordered by his physician on 11/19/2023 when the pharmacy delivered morphine ER (extended release) 15 mg tablets on 01/09/2024. The medication had been signed as administered 37 times between 1/15/25 and 2/5/25. The discrepancy had not been detected until surveyor inquiry on 02/05/2025. This failure placed the residents at risk of not receiving medications as ordered by the physician and a not receiving the intended therapeutic effect of their medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that it is free of medication error rates of five percent or greater. The facility had a medication error rate of 9%, based on 3 errors out of 32 opportunities, which involved two (Resident #107 and Resident #78) of six residents reviewed for medication administration. 1. On 2/4/25 at 7:12 AM, MA F failed to administer a medication as ordered to Resident #107 by crushing Depakote DR (an anti-seizure medication) a medication that should not be crushed and attempted to administer prior to surveyor intervention. 2. On 2/4/25 at 7:40 AM, LVN C failed to administer medications as ordered to Resident #78 when he administered Morphine extended release 15 mg instead of morphine 15 mg immediate release as ordered. [...]

Inspectors wroteBased on observation, interviews, 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 two (Resident #23 and Resident #1) of five residents, three of five pill crushers, and two of two washing machines observed for infection control. 1. The facility failed to ensure CNA A changed gloves and performed hand hygiene during incontinence care for Resident #23. 2. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. 3. The facility failed to ensure the pill crushers used on Medication Carts 1, 2, and 3 were clean. 4. The facility failed to ensure the facility's two washing machines were clean. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents (Resident #90) reviewed for PASRR Level I screenings. The facility's PASRR Level 1 Screening dated 10/25/2023 had no indicators of dementia as a primary diagnosis or evidence of mental illness, the PASRR did not correctly identify Resident #90 as having a mental illness of bipolar disorder onset date 10/25/2023 when the facility did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #221) of five residents reviewed for baseline care plans. The facility failed to complete Resident #227's baseline care plan within 48 hours of admission that included the minimum required healthcare information including physician orders, dietary orders, therapy services, and social services. Resident #227 was admitted to the facility on [DATE] and her baseline care plan was not completed until 02/03/25. This failure placed residents at risk of not receiving effective and person-centered care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #1) reviewed for incontinence care. 1. The facility failed to ensure CNA B thoroughly cleaned Resident #1 during incontinence care. This failure could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residnets right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Residnet #1) of eight residents reviewed for abuse. The facility failed to protect Resident #1, who was unable to give consent for sexual activity, from sexual abuse after Resident #2 was discovered in her bed with his pants off and buttocks exposed, laying behind her on 06/30/24. The facility failed to put interventions in place to protect Resident #1 after allegations were made that Resident #2 placed his penis in her mouth on 06/30/24. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations for one (Resident #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy to ensure Resident #1 was safe from sexual abuse when Resident #2 was found in her bed on 06/30/2024. Resident #2 had not been on any supervision from the time the incident occurred through 07/03/2024. The facility failed to follow their policy and investigate the alleged or suspected sexual abuse of Resident #1 and provide notification and information to the proper authorities according to state and federal regulations. An IJ was identified on 07/03/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for one (Resident #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy and investigate an alleged or suspected sexual assault when Resident #2 was found in Resident #1's bed on 06/30/2024. The facility did not provide notification and information to the proper authorities according to state and federal regulations. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of resident needs and preferences for 5 (Residents #1, #2, #3, #4, #5) of 30 residents observed for accommodation of needs. The facility failed to ensure Residents #1, #2, #3, #4, and #5 had call lights within reach. This failure could place the residents at risk of not being able to request assistance when needed.