Willow Ridge Rehab: Resident Left on Plastic Mattress - TX
The inspection, completed January 29, 2026, was triggered by a complaint. What investigators found was straightforward: Resident 1 had been back at the facility for one week following a hospital stay. The mattress beneath her still had its original factory packaging on it. No bottom sheet had been placed on top.
The aide assigned to her that morning, CNA D, said he noticed the plastic packaging at 6:30 AM. He assumed it might be a specialized mattress, something from a hospice vendor or a compressor bed that came that way. He did not ask a nurse. He did not verify. He left her there.
CNA C, also interviewed that morning, said she did not know why whoever placed Resident 1 on the mattress didn't remove the packaging or at least extend a bottom sheet so the resident's skin wasn't in direct contact with the plastic. She acknowledged the risk immediately: skin problems.
The facility's MDS nurse said she had been doing what the facility called "angel rounds," visits where department heads go room to room to check on residents, make sure they have ice water, confirm the call light works, ask if there are any immediate concerns. She had visited Resident 1 after the resident returned from the hospital on January 19. She said she did not recall seeing the mattress packaging during that visit. On the morning of the inspection, she said she did not notice it either. "She said she did not know how she missed it."
When asked why the packaging wasn't removed before the resident was placed in bed, the MDS nurse said she could not speak to the actions of others.
The Director of Nursing said she was not aware of the situation at all until inspectors raised it that afternoon. Her position was the same as everyone else's: the expectation was that packaging came off, clean linen went on, resident went to bed. She said all nursing staff were responsible.
The administrator learned about it the same day. She told inspectors the facility had received new mattresses for all residents within the past four days. She said she had walked the rooms and, except for Resident 1, every other resident who had already received a new mattress was not lying on plastic. She said she would have the DON complete a skin assessment on Resident 1. She also said she would start an in-service on the new mattresses.
What the administrator did not explain, and what the inspection report does not resolve, is how Resident 1 ended up as the single exception. The mattresses arrived. Staff went room to room. Packaging came off every bed but one. The resident in that bed had just come back from the hospital.
The risk, named repeatedly by every staff member interviewed, was the same: skin breakdown. Bedsores. CNA D used the word directly, describing the plastic rubbing against skin. The administrator called the packaging "non-breathable plastic." The MDS nurse, the DON, the administrator, all of them knew what lying on plastic does to an elderly person's skin over days.
Nobody disputed any of this. The question the inspection report leaves open is simpler and harder: Resident 1 came back from the hospital on January 19. The inspection was January 29. That is ten days. The aide noticed at 6:30 in the morning and decided not to ask anyone. The MDS nurse visited and did not see it. The director of nursing didn't know. Angel rounds happened.
Ten days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Ridge Wellness & Rehabilitation from 2026-01-29 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: August 21, 2026 · Our methodology
Willow Ridge Wellness & Rehabilitation in Fort Worth, TX was cited for violations during a health inspection on January 29, 2026.
The inspection, completed January 29, 2026, was triggered by a complaint.
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.