FORT WORTH, TX - Federal inspectors issued an immediate jeopardy citation to Pennsylvania Nursing and Rehabilitation Center after a resident received an electrical shock from a wall outlet in her room, resulting in burns and blistering.
The incident occurred on March 16, 2025, when the resident attempted to plug in her phone charger. The electrical malfunction caused immediate injury, leaving visible burn marks and blisters on the resident's skin. Immediate jeopardy represents the most serious category of nursing home violations, indicating conditions that place residents at risk of serious injury or death.
Electrical Safety Failure Creates Immediate Risk
The electrical shock incident raised significant concerns about the facility's maintenance protocols and resident safety systems. Wall outlets in healthcare facilities must meet stringent safety standards to protect vulnerable residents, many of whom have limited mobility or cognitive impairments that prevent them from recognizing or responding to hazards.
Electrical shocks can cause burns at the point of contact, damage to internal organs, cardiac arrhythmias, and in severe cases, death. The voltage and duration of contact determine the severity of injury. Even seemingly minor shocks can trigger dangerous heart rhythm disturbances, particularly in elderly individuals with pre-existing cardiac conditions.
The resident in this case sustained visible burns and blistering, indicating a significant electrical current passed through her body. Burns from electrical contact often extend deeper than surface injuries suggest, potentially affecting muscle tissue and internal structures. Blistering indicates second-degree burn damage, which requires medical monitoring for infection risk and proper healing.
Systemic Maintenance Deficiencies Revealed
The inspection revealed that staff had not identified the faulty outlet before the resident encountered it. Federal regulations require nursing homes to maintain physical environments that protect residents from accidents and hazards. Regular inspection and maintenance of electrical systems constitute essential components of facility safety protocols.
According to industry standards, healthcare facilities should conduct routine electrical safety inspections, testing outlets for proper grounding, correct voltage, and absence of damage. Ground fault circuit interrupters (GFCIs) should be installed in areas where water contact is possible, and all outlets should be inspected for signs of wear, overheating, or damage.
The facility's failure to detect and repair the dangerous outlet before resident contact suggests deficiencies in preventive maintenance procedures. Staff should have systems in place to identify and report maintenance concerns before they result in resident injury.
Facility Response and Corrective Measures
Following the immediate jeopardy determination on April 14, 2025, the facility implemented emergency corrective actions. The maintenance director inspected all electrical outlets in resident rooms on the same day to identify additional hazards. Staff received immediate training on reporting electrical issues and other safety hazards.
The facility established new protocols requiring staff to immediately log any electrical issues in the maintenance logbook and contact the administrator by phone. Additional training addressed accident and incident prevention, with 62 staff members completing hazard awareness education and 63 staff members completing training on accident and incident prevention.
An ad hoc Quality Assurance and Performance Improvement meeting convened on April 14, 2025, with participation from the medical director, facility administrator, and director of nursing. The medical director reviewed and approved the plan for removing the immediate jeopardy status.
The facility implemented ongoing monitoring procedures, including weekly inspections of six resident rooms for four weeks to verify outlet functionality, followed by monthly inspections thereafter. The administrator assumed responsibility for checking the maintenance log daily to identify new electrical risks or other safety concerns.
Inspection Process and Violation Removal
Federal surveyors verified the facility's corrective actions through extensive interviews conducted on April 15, 2025, from 9:00 AM to 3:01 PM. Surveyors spoke with 31 staff members across all shifts, including registered nurses, licensed vocational nurses, certified nursing assistants, the maintenance director, dietary staff, and therapy personnel.
All interviewed staff demonstrated understanding of the new protocols for reporting electrical issues and other hazards. Record reviews confirmed that staff training had been completed and outlet inspections had been documented.
The immediate jeopardy status was removed on April 15, 2025, after inspectors verified implementation of corrective measures. However, the facility remained out of compliance at a lower severity level while continuing to monitor the effectiveness of the new safety systems.
Additional Pest Control Violation
The April 2025 inspection also identified a separate violation regarding pest control. On May 28, 2025, staff discovered ants in a resident's bed, with the insects on the resident's body and gown. The resident had been bitten multiple times on his torso, arms, and legs.
The affected resident had severe cognitive impairment and required substantial assistance with all activities of daily living due to stroke, hemiplegia, anoxic brain damage, and Bell's palsy. His limited ability to communicate or move independently prevented him from alerting staff to the presence of ants.
Progress notes documented the incident: "Summoned by the nurse aide that there's ants in the resident bed, arrived at the resident room noted ants on the bed and on resident's gown, resident denies being in pain at this time."
Staff relocated the resident to another room, provided bathing, and conducted a head-to-toe assessment. Initially, no ant bites were visible, but later examination revealed bites on the resident's left shoulder and upper back. A physician ordered hydrocortisone cream application every shift for seven days to treat the bites.
Pest control services treated the affected room and surrounding areas on May 28, June 2, and June 9. The resident's condition improved within several days, with redness fading and no signs of infection developing.
Ant bites pose particular risks for nursing home residents with limited mobility or impaired cognition. Beyond the immediate discomfort and skin irritation, bites can introduce bacteria that cause secondary infections, particularly problematic for individuals with compromised immune systems or diabetes. Residents who cannot communicate effectively or move independently face heightened vulnerability to prolonged exposure.
Regulatory Context and Industry Standards
The immediate jeopardy citation reflects the seriousness with which federal regulators view environmental safety failures in nursing homes. Facilities accepting Medicare and Medicaid reimbursement must comply with federal regulations requiring safe physical environments.
The Code of Federal Regulations mandates that nursing facilities must provide a safe, clean, comfortable, and homelike environment, allowing residents to use their personal belongings to the extent possible. This includes ensuring that all building systems, including electrical infrastructure, function properly and pose no risk to resident safety.
Electrical safety standards require regular testing and maintenance, prompt repair of identified defects, and systems for staff to report concerns. The presence of a faulty outlet that could deliver a shock severe enough to cause burns and blistering indicates significant maintenance failures.
Protecting Vulnerable Populations
Nursing home residents face particular vulnerability to environmental hazards due to physical limitations, cognitive impairments, and medical conditions that reduce their ability to recognize or avoid dangers. Many residents cannot quickly move away from hazards or effectively communicate problems to staff.
Electrical injuries can have particularly severe consequences for elderly individuals. Beyond the immediate burns and tissue damage, electrical shock can trigger cardiac events, exacerbate existing medical conditions, and cause psychological trauma. For residents with pacemakers or other implanted devices, electrical current poses additional risks to proper device function.
The facility's response to the immediate jeopardy citation demonstrates the type of comprehensive action required when serious safety failures are identified. Immediate inspection of all similar hazards, thorough staff education, establishment of reporting protocols, and ongoing monitoring constitute essential components of corrective action plans.
Pennsylvania Nursing and Rehabilitation Center is located at 901 Pennsylvania Avenue in Fort Worth, Texas. The facility is also known as Arbor Lake Nursing & Rehabilitation LLC. The inspection was conducted on April 15, 2025, as part of a complaint investigation process.
Readers can access the complete inspection report through the Medicare Nursing Home Compare website or by contacting the Texas Health and Human Services Commission survey agency for detailed information about identified deficiencies and facility responses.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pennsylvania Nursing and Rehabilitation Center from 2025-04-15 including all violations, facility responses, and corrective action plans.
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