Cityview Nursing and Rehab: Soiled Linens Left Unchanged - TX
The man, identified in inspection records only as Resident #1, was in his sixties and had been admitted to the facility the previous December. His diagnoses included intestinal cancer that had spread throughout his body, a mass on his left kidney requiring a drainage tube, and acute kidney failure. He was on a diuretic, a medication that increases urination by pulling excess fluid from the body. His care plan documented that he was incontinent of both bowel and bladder and dependent on staff for toileting hygiene.
His mind was fully intact. His cognitive score placed him in the normal range.
When the inspector observed him at 11:09 a.m. on January 29, the draw sheet beneath him was brown, the color of dried urine. He told the inspector his bedding had not been changed since the previous evening. He said no one had come in that morning. He said he hadn't realized he was lying in it and hadn't called for help because he didn't know it had happened.
The certified nursing aide assigned to his hall, identified as CNA-A, told the inspector four minutes later that she hadn't checked on him yet. She said she had been busy with other residents. She didn't know he had been incontinent. She said she did not feel overworked because there were other aides working the hall.
The assistant director of nursing said there was no reason the resident should have been left that way. He said the night shift should have caught it before leaving, and that CNA-A should have found it when she made her morning rounds. He described his expectation plainly: nurses and aides were to round on all their residents at the start of each shift to assess for needs. He acknowledged that lying in urine-soaked linen carries the risk of skin breakdown and irritation.
When the inspector examined the resident's skin, there was no breakdown or open excoriation. There was some redness from lying on his back.
Other residents on the hall told inspectors they had no complaints. Staff checked on them, they said. Their needs were being met.
The facility's own policy on activities of daily living, last updated in May 2023, listed bathing, dressing, grooming, oral care, and toileting among the care and services it committed to providing. It said nothing specific about changing soiled linens.
The inspection, conducted as a complaint survey, cited the facility for failing to provide a clean and comfortable environment. The finding covered one of seven residents reviewed and was rated at the lower end of the harm scale, meaning inspectors found minimal harm or the potential for actual harm rather than serious injury. The citation noted the failure placed the resident at risk of skin breakdown and, in the language of the report, "decreased feelings of self-worth."
That phrase, clipped and bureaucratic, sits at the end of a findings summary describing a man with terminal cancer, on a diuretic, cognitively aware, lying alone in wet bedding since the night before, not knowing anyone would come.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cityview Nursing and Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
Cityview Nursing and Rehabilitation Center in Fort Worth, TX was cited for violations during a health inspection on January 29, 2026.
The man, identified in inspection records only as Resident #1, was in his sixties and had been admitted to the facility the previous December.
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.