Inspection Reports for Village Creek Wellness and Rehabilitation
3825 Village Creek Rd, Fort Worth, TX 76119, United States, TX, 76119
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
109% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care and treatment for residents, specifically reviewing quality of care related to a fall and subsequent treatment of swelling for Resident #1.
Findings
The facility failed to ensure Resident #1 received timely identification and treatment of swelling on the cheekbone following a fall, resulting in delayed care. Documentation and staff interviews revealed inconsistent reporting and communication regarding the resident's injury and condition.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically failure to identify and treat swelling on Resident #1's cheekbone after a fall.
Report Facts
Residents reviewed for quality of care: 5
Falls on 10/09/2025: 2
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hospice Nurse E | Hospice Nurse | Identified swelling on Resident #1's face and documented observations |
| LVN A | Licensed Vocational Nurse | Assigned nurse during Resident #1's fall and assessments; interviewed regarding injury and communication |
| CNA B | Certified Nursing Assistant | Assisted with Resident #1's care and observed facial swelling after fall |
| CNA D | Certified Nursing Assistant | Assisted with Resident #1's transfer and observed facial bump |
| LVN C | Licensed Vocational Nurse | Nurse assigned during second shift; monitored Resident #1 and interviewed about injury reporting |
| DON | Director of Nursing | Reported on Resident #1's falls and facility's response to injury and reporting |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to medication management, drug regimen monitoring, medication storage, and pest control in the nursing facility.
Findings
The facility was found deficient in ensuring licensed pharmacist drug regimen reviews were acted upon, specifically failing to include anti-psychotic side-effect monitoring orders for Resident #10. Additionally, the facility failed to ensure residents' drug regimens were free from unnecessary drugs, failed to secure medication carts properly, and failed to maintain an effective pest control program, as ants were found in Resident #73's room.
Deficiencies (4)
Failed to ensure licensed pharmacist drug regimen irregularities were acted upon, specifically missing anti-psychotic side-effect monitoring orders for Resident #10's Risperdal and Perphenazine medications.
Failed to ensure each resident's drug regimen was free from unnecessary drugs; Resident #10 was not monitored for side-effects related to anti-psychotic medications.
Failed to ensure all drugs were stored in locked compartments; Medication Cart #3 drawer #2 was unlocked and accessible.
Failed to maintain an effective pest control program; ants were found in Resident #73's room.
Report Facts
Residents reviewed for medication regimens: 5
Medication carts reviewed: 6
Resident rooms reviewed for pest control: 6
Ants observed: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN F | Licensed Vocational Nurse | Resident #10's nurse who monitored for side-effects and reported missing side-effect monitoring orders. |
| ADON | Assistant Director of Nursing | Responsible for completing and following up on pharmacy recommendations; acknowledged missing side-effect monitoring orders. |
| DON | Director of Nursing | Reviewed Resident #10's orders and confirmed missing side-effect monitoring orders; responsible for oversight. |
| RN A | Registered Nurse | Observed medication cart #3 unsecured and reported issue. |
| Maintenance Director | Reported pest control procedures and response to ant infestation in Resident #73's room. | |
| Administrator | Notified pest control company and coordinated resident relocation and assessment due to ant infestation. | |
| CNA B | Certified Nursing Assistant | Reported procedures for pest sightings and resident safety. |
| MA C | Medication Aide | Reported no ants observed but would notify staff if seen. |
| CNA D | Certified Nursing Assistant | Reported no ants observed but described procedures if pests were found. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding alleged abuse of Resident #8 by a Hospice Aide on 05/08/2024.
Complaint Details
The complaint was substantiated. The Immediate Jeopardy began and ended on 05/08/2024. The Hospice Aide was observed striking Resident #8 and telling her to be quiet. The Hospice Aide was removed from the facility immediately, and the incident was reported to the police and State Survey Agency.
Findings
The facility failed to ensure Resident #8 was free from abuse when a Hospice Aide was observed striking the resident and telling her to be quiet. Immediate Jeopardy was identified but corrected before the survey began. The Hospice Aide was removed from the facility, staff were re-inserviced on abuse prevention, and the incident was reported to authorities.
Deficiencies (1)
Failure to protect Resident #8 from abuse by a Hospice Aide who struck the resident and told her to be quiet.
Report Facts
Date of abuse incident: May 8, 2024
Date of survey completion: Jul 11, 2024
Residents reviewed for abuse: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Witnessed the abuse incident and reported it | |
| LVN B | Licensed Vocational Nurse | Responded to the abuse incident and assessed Resident #8 |
| DON | Director of Nursing | Received report of abuse and coordinated response |
| Administrator | Informed about the abuse incident and oversaw corrective actions |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, privacy, abuse prevention, feeding tube management, dialysis care, PASRR screening, and clinical record maintenance at Village Creek Nursing & Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment with broken window blinds, failure to prevent abuse by a hospice aide, inaccurate PASRR screening documentation, improper feeding tube care, inadequate post-dialysis assessments and documentation, failure to notify physicians of high blood sugar levels, incomplete clinical records, and lack of privacy curtains in a triple occupancy room.
Deficiencies (7)
Failure to maintain total visual privacy by allowing window blinds in rooms 302, 308, and 310 to be broken and missing several slats.
Failure to ensure residents were free from abuse; hospice aide struck Resident #8 and told her to be quiet.
Failure to ensure accurate PASRR Level 1 screening for Resident #10 with proper mental illness diagnoses.
Failure to flush Resident #48's feeding tube with 60cc of water before bolus feeding as ordered.
Failure to ensure post-dialysis assessments and documentation were completed for Resident #18 after dialysis treatment.
Failure to maintain complete and accurate clinical records for Residents #18 and #28, including lack of physician orders for dialysis monitoring and failure to document physician notification for high blood sugar.
Failure to provide privacy curtains between beds A and B in a triple occupancy room, compromising resident privacy and dignity.
Report Facts
Residents reviewed for environment: 10
Residents affected by broken blinds: 3
Residents reviewed for abuse: 3
Residents affected by abuse: 1
Residents reviewed for PASRR screening: 6
Residents reviewed for feeding tubes: 3
Residents reviewed for dialysis: 4
Residents reviewed for clinical records: 6
Blood sugar readings exceeding 250 mg/dL: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Witnessed hospice aide abuse of Resident #8 and reported incident | |
| LVN B | Licensed Vocational Nurse | Responded to abuse incident involving Resident #8 and hospice aide |
| LVN E | Licensed Vocational Nurse | Nurse assigned to secure unit who reported broken window blinds and privacy curtain issues |
| LVN C | Licensed Vocational Nurse | Failed to flush feeding tube before bolus feeding for Resident #48 |
| LVN F | Licensed Vocational Nurse | Nurse assigned to Resident #28 who failed to document physician notification of high blood sugar |
| LVN G | Licensed Vocational Nurse | Responsible for dialysis communication form for Resident #18; admitted inconsistent monitoring |
| Maintenance Manager | Responsible for maintenance of window blinds and privacy curtains | |
| Administrator | Stated responsibility of staff to report broken blinds and ensure privacy curtains | |
| MDS Coordinator | Failed to ensure accurate PASRR screening for Resident #10 | |
| Regional MDS Nurse | Responsible for overseeing PASRR screenings | |
| DON | Director of Nursing | Provided multiple interviews regarding abuse incident, feeding tube care, dialysis monitoring, and clinical record documentation |
| ADON | Assistant Director of Nursing | Responsible for ensuring dialysis communication forms were completed |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and failure to prevent accidents, specifically related to Resident #1 who sustained injuries from a fall.
Complaint Details
The complaint investigation was substantiated. Resident #1 sustained injuries including contusions, bruises, and a subdural hematoma after sliding out of her wheelchair on 05/08/24. The facility failed to provide adequate supervision and failed to properly document and investigate the incident. The family requested hospital transfer due to the injuries. The facility took corrective actions including staff training and disciplinary measures.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in Resident #1 sustaining contusions, bruises, and a subdural hematoma after sliding out of her wheelchair. The facility also failed to properly document and investigate the incident as required by policy. Staff interviews and record reviews confirmed these deficiencies and subsequent corrective actions were initiated.
Deficiencies (2)
Failure to ensure adequate supervision and prevent accidents for Resident #1, resulting in actual harm.
Failure to initiate and document investigation of an incident/accident on 05/08/24 as per facility policy.
Report Facts
Residents reviewed for accidents and supervision: 4
Resident #1 age: 77
Incident report numbers: 2
Dates of key events: Fall occurred on 05/08/24; hospital admission on 05/09/24; report completed 05/25/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Failed to initiate and document investigation of incident on 05/08/24; received written warning and retraining. |
| LVN B | Licensed Vocational Nurse | Admitted Resident #1 on 04/29/24; observed bruising and reported to family and DON. |
| CNA C | Certified Nursing Assistant | Witnessed Resident #1 sliding out of wheelchair on 05/08/24 and sought help to assist resident. |
| DON | Director of Nursing | Counseled LVN A and oversaw corrective actions and staff training. |
| DOM | Director of Maintenance | Assisted CNA C in helping Resident #1 off the floor. |
| NFA | Nurse Facility Administrator | Reported incident to state agency and police; initiated internal investigation. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 3, 2024
Visit Reason
The inspection was conducted as an annual survey of Village Creek Nursing & Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
This document is a statement of deficiencies and plan of correction for Village Creek Nursing & Rehabilitation, summarizing the findings of the survey completed on 09/26/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Village Creek Nursing & Rehabilitation following a survey completed on 09/07/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 6
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, medication management, nursing services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans, inadequate pressure ulcer care, insufficient RN coverage, incomplete pharmacist irregularity follow-up, unsanitary kitchen conditions, and failure to disinfect reusable equipment between resident use.
Deficiencies (6)
Failed to develop and implement a comprehensive person-centered care plan for Resident #81, including failure to update smoking status.
Failed to provide appropriate pressure ulcer care and prevent new ulcers for Resident #37, including failure to update physician wound care orders and order wound supplies.
Failed to have a registered nurse on duty for at least eight consecutive hours a day for 16 of 34 days reviewed.
Failed to ensure pharmacist irregularities were reported and acted upon for 4 residents, including incomplete informed consents and missing medication hold parameters.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including unsanitary kitchen ceiling and vents.
Failed to maintain an infection prevention and control program by not disinfecting blood pressure cuffs between residents.
Report Facts
Residents reviewed for comprehensive care plans: 18
Residents reviewed for pressure ulcers: 2
Days without 8 consecutive hours RN coverage: 16
Residents reviewed for drug regimen reviews: 7
Residents receiving antipsychotic medications: 17
Residents receiving antidepressant medications: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Wound Nurse | Named in failure to update wound care orders and failure to order wound supplies for Resident #37 |
| LVN E | Wound Nurse | Named in wound care observation for Resident #37 and lack of knowledge of new wound care orders |
| DON | Director of Nursing | Named in multiple findings including failure to ensure care plan updates, RN coverage oversight, and pharmacist irregularity follow-up |
| MDS Coordinator | Responsible for updating care plans including Resident #81's smoking status | |
| Social Worker | Interviewed regarding Resident #81's smoking status and safe smoking assessment | |
| Staffing Coordinator | Responsible for nursing schedules, unaware of requirement for 8 consecutive hours RN coverage | |
| Administrator | Oversaw nursing schedules and kitchen sanitation policies | |
| MA C | Medication Aide | Failed to disinfect blood pressure cuffs between resident use |
| Dietary Manager | Responsible for kitchen cleaning schedules and sanitation | |
| Maintenance Director | Responsible for cleaning vents and ceiling filters in kitchen | |
| Nurse Practitioner | Acknowledged pharmacist recommendation for heart rate parameters for Resident #78 | |
| MA B | Medication Aide | Described medication administration practices including hold parameters |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding resident dignity and privacy, specifically related to the care and coverage of urinary catheter collection bags.
Findings
The facility failed to ensure that Resident #1's urinary catheter collection bag was covered with a privacy bag, which could lead to a loss of dignity and decreased self-esteem. Interviews with staff confirmed the responsibility to cover the bags and acknowledged the failure to do so on the day of observation.
Deficiencies (1)
Failure to promote Resident #1's dignity by not covering his catheter urinary collection bag with a privacy bag.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Assisted Resident #1 with a shower and reported the urinary collection bag did not have a cover. |
| LVN A | Licensed Vocational Nurse | Nurse for Resident #1 who acknowledged the urinary collection bag should always be covered and was not notified about the missing privacy bag. |
| DON | Director of Nursing | Stated staff responsibility to ensure urinary collection catheter bags are covered and noted the negative impact on resident dignity and privacy when not covered. |
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