Sex assaults, a missing person and accidental death: Feds single out Fort Worth nursing home

Residents at a Fort Worth nursing home suffered multiple abuses last year, including two residents who were sexually assaulted by their peers, one resident who left the nursing home and whose whereabouts were unknown for four days, and one woman whose fall at the nursing home later led to her death, according to reports from state inspectors.

These incidents and others moved the federal government to add the home — Trail Lake Nursing & Rehabilitation — to the Special Focus Facility list. The designation makes the Fort Worth facility, at 7100 Trail Lake Drive, one of 88 in the nation singled out for additional scrutiny because of a “history of serious quality issues,” according to the Centers for Medicare & Medicaid Services.

The nursing home is managed by Trinity Healthcare, a Fort Worth-based company that operates 25 nursing homes in Texas, according to its website.

In a statement, a spokesperson for the nursing home said although the facility had been added to the Special Focus Facility list, it “maintains a commendable four-star quality measure rating” based on the Centers for Medicare & Medicaid Services five-star quality rating.

“This rating underlines our commitment to resident care and quality outcomes. Our inclusion on the Special Focus Facility list is due to not meeting specific criteria in the past,” the statement read. “We are fully committed to promptly and comprehensively addressing these issues.”

The nursing home’s overall rating is one star out of five, according to the ratings program.

In the last three years, the nursing home has been fined more than $177,000. The home, which has 120 beds, averages about 61 residents per day, according to the federal government.

A string of inspections in 2023 identified serious safety issues for residents.

In August, a man with ALS was assaulted after he was temporarily moved to new room for a wound care exam. The man was supposed to have a “communication device with him at all times to communicate effectively with staff and others,” according to an investigation completed later. After the man’s wound exam was completed, he was left alone in the room with his new roommate, who molested him. Without his communication device, the patient couldn’t alert anyone as he was being touched. A certified nursing assistant even interrupted the assault by walking into the room, according to the report, but the patient was unable to tell her what had just happened without his communication device.

Two months later, in October, a different patient was assaulted by her roommate. The two were in a consensual romantic relationship at the time, according to the state’s report. The woman “yelled for help” and told her roommate that “he was hurting her leg” as he assaulted her, according to the report. Trail Lake’s spokesperson said in an email that the nursing home had “developed a plan to improve our response in any future situations, which was reviewed and accepted by the state regulators.”

In June, a resident fell while at the nursing home, and the facility “failed to immediately inform the physician and the resident’s representative.” The woman’s injury resulted in her “developing a subdural hematoma which ultimately resulted in her death.”

And in February, a resident left the facility during freezing cold temperatures, and his whereabouts were unknown for four days. The resident was found “in stable health and chose not to return to the facility,” Trail Lake’s spokesperson said.

Nursing homes across the nation are facing additional scrutiny over their health and safety standards in the wake of the COVID-19 pandemic.