Ft Worth Southwest Nursing Center

In the surveyor’s words

From the most serious findings on record at Ft Worth Southwest Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jul 27, 2021

  Based on observations, 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 for 12 (Residents #5, #20, #24, #55, #18, #35, #60, #61, #85, #92, #93 and #354) of 29 Residents and three (#100, #300 and #400) of three halls and one (400 hall storage room) of three storage rooms reviewed for infection control. The DON and MDS Coordinator LL failed to identify Resident #354 readmitted on [DATE] with [CONDITION(S)], until HHSC State Surveyors told them. The facility failed to adequately train staff and monitor to ensure staff followed their infection control policy. […]

• Immediate jeopardy, patternF600Jul 27, 2021

  Based on observations, interviews and record reviews the facility failed to ensure residents had the right to be free from neglect for 10 (Residents #5, #19, #24, #44, #54, #60, #78, #99, #101 and #354) of 29 residents and one (Resident #56) of two residents reviewed for Abuse. A)The facility only had one wound care nurse which resulted in the facility not providing adequate skin assessments and treatments for residents with skin conditions and pressure ulcers/injuries. ADON A failed obtain more wound care training, her Wound care certification was from April 2016. The facility failed to adequately train staff and monitor to ensure staff followed their infection control policy. ADON A was the Infection Control Preventionist and failed to follow the facility's infection control policy. […]

• Immediate jeopardy, patternF686Jul 27, 2021

  Based on observations, interviews and record reviews the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 10 (Residents #5, #19, #24, #44, #54, #60, #78, #99, #101, #354) of 29 residents reviewed for Pressure ulcers/injuries. ADON A failed obtain more wound care training, her Wound care certification was from 2016. The facility failed to properly assess and treat Resident #60's skin infected wounds who had abnormal labs with an elevated white blood CBC on 07/13/21 and not sent to the hospital until 07/25/21. […]

• Immediate jeopardy, patternF695Jul 27, 2021

  Based on observation, interview and record review the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for three (Resident's #59, #85 and #100) of three residents reviewed for oxygen orders. The facility failed to provide oxygen therapy (10 liters per minute of oxygen via [CONDITION(S)] collar) for Resident #59 as ordered by the physician. The facility failed to provide oxygen therapy (2 liters per minute of oxygen via [CONDITION(S)] collar) for Resident #85 as ordered by physician. The facility failed to provide oxygen therapy (5 liters per minute of oxygen via [CONDITION(S)] collar) for Resident #100 as ordered by physician. […]

• Immediate jeopardy, isolatedF600Jul 4, 2024

  Based 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. […]