Ft Worth Southwest Nursing Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

He stated he was aware of the broken window and had already purchased some material to repair it. The Maintenance Director stated he started working at the facility on 09/15/25, and the window was broken then. The Maintenance Director stated he would be fixed today. He stated the risk of a broken window in a resident room was the resident could cut themselves on it.In an observation and interview on 10/14/25 at 1:21 PM, reflected Resident #3's room was the room with the broken window. Upon further observation, the broken window had green tape of some of the cracks. There was a broken, open area with no coverage.

The window was open. Resident #3 stated she did not realize the window was that bad. Resident #3 stated

she was not sure how long the window had been broken. She stated she was not sure who opened the window. Resident #3 stated she hoped maintenance would repair the window soon, and she hoped it would be repaired the same day. In an interview on 10/14/25 at 3:08 PM, the Administrator stated the risk of a broken window in a resident's room was pest control concerns. In an interview on 10/15/25 at 1:21 PM, Resident #2's Family Member stated they had complained to the facility two times in the past regarding his room not being cleaned. The Family Member stated it was mostly on the weekend, and the facility staff told them there were not as many housekeepers who worked on the weekend. The Family Member stated they would like Resident #2's room to be cleaned more consistently. Record review of the facility's policy titled, Resident Rights, dated 08/2020, reflected the following: Purpose To promote and protect the rights of all residents at the facility. Policy All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

FT Worth Southwest Nursing Center

5300 Alta Mesa Blvd Fort Worth, TX 76133

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of five (Resident #1 Room) resident rooms reviewed for pharmacy services. The facility failed to ensure a tube of Zinc Oxide Ointment and a bottle of Antiseptic Skin Cleanser were not left in Resident #1's room. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.Findings included:In an observation and interview on 10/10/25 at 10:11 AM, an uncapped, 1 oz tube of Zinc Oxide ointment was observed on Resident #1's nightstand, and a 4 oz bottle of Antiseptic Skin Cleanser was observed on top of Resident #1's refrigerator, which sat on top of the nightstand. Resident #1 stated staff must have left those items in his room this morning. Resident #1 stated the staff kept all of his medications.In an interview on 10/10/25 at 10:45 AM, RN A stated the aides were responsible for applying creams and ointments. She stated prescription creams and antiseptic would be administered by a nurse.

RN A stated the zinc oxide was applied by Aide B this morning, and she stated she was not sure where the antiseptic came from. RN A stated she did not put any antiseptic on him this morning and was not sure if it was from Resident #1's home or the facility. RN A stated those items should not be left in Resident #1's room where a resident could have access to those items. In an interview on 10/10/25 at 11:03 AM, Aide B stated she did use the zinc oxide on Resident #1 this morning while changing him. Aide B stated she was rushing to answer another call light and must have left the ointment in his room. She stated she did not have the antiseptic skin cleanser and was not sure who was responsible for it. Aide B stated she was not supposed to leave ointment in the resident's room, but she was rushing and forgot. Aide B stated the risk was Resident #1 could have got it or touched it.In an interview with the Administrator and the DON on 10/10/25 at 2:18 PM, the DON stated those items should not be left in Resident #1's room. He stated the facility started an in-service to remind staff not to leave medications, ointments, and cleansers in the residents' rooms. The DON stated the risk of leaving those items in Resident #1's room was there was potential for harm, like the resident ingesting something. The Administrator stated the risk of leaving those items in Resident #1's room was possible sickness.Record review of the facility's undated policy, titled, Medication Administration, reflected the following: PurposeTo provide practice standards for safe administration of medications for residents in the Facility. VIII. Medications will not be left at the bedside.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

FT Worth Southwest Nursing Center

5300 Alta Mesa Blvd Fort Worth, TX 76133

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #1) of 5 residents records reviewed for treatment documentation. 1. The facility failed to document timely when Resident #1 refused to leave the courtyard area of the facility until 1:00 AM on 10/08/25. This failure could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Record review of Resident #1's face sheet, dated 10/10/25, reflected a [AGE] year-old male, with an initial admission date of 06/17/25, and a readmission date of 10/02/25. Resident #1 had a diagnoses of Parkinson's Disease (progressive disorder that affects movement, balance, and coordination), Type 2 Diabetes (body does not use insulin properly or cannot produce enough insulin), Schizoaffective Disorder (disorder with delusions, hallucinations, disorganized thinking, depressed mood, and manic behavior), Bipolar Disorder (mental health condition with extreme mood swings), Anxiety Disorder (excessive worry, fear, or nervousness), Chronic Pain, Blindness in one eye and low vision in the other eye, Essential Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (airflow obstruction and breathing difficulties), and Dysphagia (difficulty swallowing). Record review of Resident #1's quarterly MDS, dated [DATE REDACTED], reflected Resident #1 had a BIMS score of 12, which meant Resident #1 had moderate cognitive impairment. Record review on 10/10/25 of the progress notes on Resident #1's electronic record, reflected no note about Resident #1's refusal to leave the courtyard until 1:00 AM. In an interview on 10/10/25 at 12:29 PM, LVN C stated he was

the one that repeatedly checked on Resident #1 in the courtyard of the facility on the night of 10/08/25. LVN C stated when his shift started that night around 10:00 PM, the previous shift staff informed him Resident #1 was in the courtyard and was not ready to come back into the facility. LVN C stated he checked on Resident #1 about every 20-30 minutes. LVN C stated Resident #1 kept saying he was enjoying the fresh air and was not ready to leave the courtyard. LVN C stated finally, around 1:00 AM, Resident #1 was ready to leave the courtyard. He stated he was then taken back to his room. LVN C stated the residents have rights, and he could not make Resident #1 leave the courtyard. LVN C stated he felt there was no risk of not documenting when Resident #1 did not want to leave the courtyard, because he went to the courtyard often, but he normally would not be out there as late as he was on 10/08/25. Record review on 10/14/25 of

the progress notes on Resident #1's electronic record reflected a late entry note, added on 10/13/25 at 3:16 AM on the incident on 10/08/25, when Resident #1 refused to leave the courtyard at the facility until around 1:00 AM. In an interview with the Administrator and the DON on 10/14/25 at 3:08 PM, the DON stated the risk of late documentation when Resident #1 refused to come inside was important information missing from the resident's electronic record that needs to be shared with the clinical team. The Administrator stated

she agreed with the DON about the risk of late documentation on a resident's electronic record. The Administrator stated the staff will be reviewing documentation during the morning review to ensure information is not missed. Record review of the facility's policy titled, Documentation-Nursing, dated, 01/2025, reflected the following: PurposeTo provide documentation of resident status and care given by nursing staff.PolicyNursing documentation will be concise, clear, pertinent, accurate and evidence based.K.

Documentation will be completed by the end of the assigned shift.

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