Benbrook Nursing & Rehabilitation: Care Order Failures - TX
The citation, issued September 11, falls under a category regulators call Quality of Life and Care deficiencies. It is among the more direct failures inspectors can document: not a lapse in paperwork, not a missing signature, but a gap between what a resident's care plan required and what actually happened.
Inspectors classified the violation at Scope and Severity Level D, meaning it was isolated and did not produce documented harm to any resident. That classification does not mean nothing was at risk. At Level D, inspectors have determined the failure carried potential for more than minimal harm, the threshold that separates a technical paperwork problem from a finding with real clinical weight.
The facility reported the deficiency corrected two days later, on September 13.
What the inspection report does not describe, at least in the summary available, is which resident or residents were affected, what specific orders went unfollowed, or what the gap between ordered care and delivered care looked like in practice. The narrative is thin. A physician may have ordered a particular wound care protocol that nurses did not follow on schedule. A resident may have expressed a clear preference about how or when they received a treatment, and staff may have ignored it. The inspection record, as summarized, does not say.
What it does say is that this was not the only problem inspectors found.
Twelve deficiencies in a single inspection is not a minor result. A facility can receive citations for issues ranging from meal temperature to infection control to the way it handles residents' money, and not every citation signals the same level of risk. But twelve findings in one visit, including one tied directly to whether residents receive the care their doctors ordered, describes a facility where inspectors found problems across multiple areas of operation.
The care-order deficiency sits in a category that tends to matter more to residents and families than to regulators filling out forms. The promise of a nursing home, at its most basic, is that when a doctor writes an order for a resident, that order gets carried out. When a resident tells staff how they want to be treated, that preference shapes the care they receive. The inspection found that promise was not being kept, at least in one documented instance.
Benbrook Nursing & Rehabilitation Center is a long-term care and rehabilitation facility in Benbrook, a city of roughly 25,000 people on the western edge of the Fort Worth metro area. The September 11 inspection was a complaint inspection, meaning it was triggered by a specific concern reported to regulators rather than a routine scheduled survey.
The facility's two-day correction turnaround is notable. Whether that speed reflects a genuine fix or a rapid documentation response is something the inspection record does not resolve.
For families with relatives at Benbrook Nursing & Rehabilitation Center, the twelve-deficiency inspection is the kind of result that warrants a direct conversation with the facility's director of nursing or administrator, a review of their loved one's current care plan, and a request to see documentation that ordered treatments are being delivered on schedule. A Level D finding with no documented harm can become something worse if the underlying gap in care is not actually closed.
The inspection record shows a correction date. It does not show what changed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benbrook Nursing & Rehabilitation Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Benbrook Nursing & Rehabilitation Center in Benbrook, TX was cited for violations during a health inspection on September 11, 2025.
The citation, issued September 11, falls under a category regulators call Quality of Life and Care deficiencies.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.