Fort Worth Transitional Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents, including the quality and timeliness of the services, for one (Resident #1) of three residents reviewed for laboratory services. The facility failed to ensure Resident #1 received a re-draw of lab work following her refusal for services on 07/02/26. This failure could result in residents not receiving timely interventions and care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 2 of 4 residents (Resident #71, Resident #8) reviewed for respiratory care.1. The facility failed to provide tracheostomy care and tracheal suctioning for Resident #71 when she experienced shortness of breath and was transferred to the hospital and had her trache replaced in the emergency room2. The facility failed ensure an Ambu bag (a handheld, self-inflating device that forces air or oxygen into the lungs during emergencies) an emergency equipment was available in Resident #8's room.3. The facility failed to monitor the Resident #8 oxygenation status during high-risk procedure when suctioning.4. [...]

Inspectors wroteBased on observations and interviews, and record reviews the facility failed to ensure residents receiving enteral nutrition (g tube) received appropriate care, treatment and service to maintain nutritional status to prevent complications and ensure safe feeding practices consistent with professional standards of practice for 2 (Residents #71 and Resident #8) of 4 residents reviewed for enteral feeding. The facility failed to monitor for complications related to Resident #71 feeding tube and tube feeding when Resident #71 was transferred to the hospital and had part of the g-tube replaced. The facility failed to ensure LVN F allowed Resident's #8 medication to flow by gravity while administering through G-Tube on 04/07/2026 and not using force. This failure could put residents at risk of inaccurate delivery of prescribed nutrition and medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store Drugs and biologicals under proper temperature controls in accordance with State and Federal laws on two residents (Resident#13,Resident# (300 and 200 hall nurses medication cart) of 4 medication carts reviewed for medication storage. 1. The facility failed to ensure Resident#13's opened vial of Lorazepam was not refrigerated and was stored in the medication cart.2. The facility failed to ensure opened Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (a long-acting human insulin) was properly labeled with resident name before it was stored in the medication cart.3. The facility failed to ensure two bottles of nystatin were properly labeled with patients label after opening and before it was stored in the medication cart.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions and services needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #119) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #119 within 48 hours of her admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #14) reviewed for comprehensive care plans. The facility failed to ensure Resident #14's comprehensive care plan identified bed rail use as an intervention for mobility assistance. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure correct use of bed rails and to assess the resident for risk of entrapment from bed rails for 1 (Resident #7) of 4 residents whose records were reviewed for the use of side rails. The facility failed to complete a quarterly bed rail assessment and have a current physician's order for the continued use of Resident #7's siderails. This failure could place residents at risk of entrapment or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, administering and disposition of all controlled drugs for 2 (Resident #79, and Resident #3) of 10 residents reviewed for pharmacy services.1. The facility failed to ensure proper disposal of Resident#79's Tylenol 300/30mg (controlled medication) by taping the blister pack of a narcotic medication.2. The facility failed to ensure nursing staff reconstituted Resident#3's IV medication prior to administration. This failure could place residents at risk of drug diversion, medication errors, and risk of pills contamination due to broken seals. Findings Included1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to must provide each resident with the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and care plan by ensuring a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care. The facility failed to provide Resident #1 assistance with timely incontinence care for at least 4 hours on 10/23/25, which resulted in Resident #1 being soaked with urine and soiled through her brief, draw sheet, and bed sheets. This failure could place the residents at risk for decreased feeling of self-worth, skin breakdown, and infection.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were provided an environment that was free from accident hazards for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's mattress overlay was properly secured to prevent her from falling out of bed. This failure could place residents at risk of falls and resulting injuries.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents. RN A and CNA B failed to monitor/supervise Resident #1 on 05/27/25 who suffered a fall and laid on the floor for 3 hours before being found. The resident sustained a broken leg as a result of the fall. The noncompliance was identified as past noncompliance that began on 05/27/25 and ended on 05/28/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received treatment to prevent complications of enteral feedings for 1 of 1 resident (Resident #2) reviewed for enteral feedings. CNA H paused the resident's feeding pump for perineal care and failed to re-start the pump after the care was completed, or ask a nurse to re-start it. This failure could place the resident at risk of not receiving the prescribed nutritional calories she required.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents and failed to be responsible for the quality and timeliness of the services for one (Resident #1) of five residents reviewed for laboratory services. The facility failed to complete Resident #1's lab order for a urinalysis with C&S (a diagnostic test that involves analyzing a urine sample to detect and identify potential infections and determine their susceptibility to antibiotics) as ordered by the physician. The failure could place residents at risk for delays in the provision of treatment for laboratory abnormalities and acute exacerbation of clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 16 residents (Residents #26, #32, #37, #54, and #194) reviewed for care plan accuracy. 1. The facility failed to develop and implement care plans for Residents #26, #32, #37, and #54, which addressed the residents' physician orders to be weighed weekly. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #28) of ten residents reviewed for nutrition. The facility failed to ensure Resident #28 maintained an acceptable weight causing her to trigger a -7.75 percent weight loss. The facility failed to provide weekly weight checks for Resident #28 beginning 12/19/24 with missing dates of 12/19/24, 12/26/24, 01/02/25, 01/09/25, 01/17/25, 01/23/25. These failures placed residents at-risk for weight loss and inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 3 residents (Residents #44 and #54) reviewed for oxygen. 1. The facility failed to have accurate physician orders for Resident #44's oxygen use. 2. The facility failed to ensure Resident #54, who was ventilator dependent, was repositioned every two hours to assist the resident in expectorating secretions. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one resident (Resident #56) of five residents whose medications were reviewed. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #56's Duloxetine (used to treat depression) and Zolpidem (used to treat insomnia) on 08/19/24. The facility failed to ensure this was communicated to the resident's primary care physician regarding the recommendation. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident #56) of 3 residents reviewed for unnecessary medications/ gradual dose reduction. The facility failed to ensure a gradual dose reduction (GDR) was attempted or to document contraindication for a gradual dose reduction for Resident #56's ordered Duloxetine (an antidepressant used to treat depression) and Zolpidem (a sedative-hypnotic used to treat insomnia). This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the menus were followed for 1 (the lunch meal on 01/28/25) of 2 meals reviewed for menus. The facility did not serve the posted lunch menu of roast beef, red cabbage, dill potatoes, or ice cream on 01/28/25. This failure could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs and preferences for one meal (the lunch meal on 01/28/25) of three meals reviewed for frequency of meals. The facility failed to ensure residents received meals at regularly scheduled times for lunch on 01/28/25. This failure could place residents who eat from the facility's kitchen at risk of increased hunger.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 3rd floor's satellite kitchen. 1. The facility failed to ensure drinks leaving the 3rd floor's satellite kitchen were covered before being put on the hall cart to be delivered to residents eating in their rooms. 2. The facility failed to ensure the five steamtable compartments on the 3rd floor's satellite kitchen were clean and free of debris before food was placed in them. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 2 dining rooms (Third Floor dining room) reviewed for pest control. The facility failed to ensure the Third Floor dining room was free of roaches. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each reaident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #194) reviewed for supervision. CNA A failed to safely transfer Resident #194 on 01/15/25, which resulted in the resident having to be lowered to the floor. The failure placed residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 (Resident #22) of 3 residents reviewed for bedrails. The facility failed to obtain a bed rail assessment and physician's order prior to the installment of Resident #22's bedrails. This failure could place residents at risk of entrapment or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Residents #194) reviewed for clinical records. The facility failed to ensure LVN B documented on Resident #194's clinical record that he had a fall. This failure could affect residents that required assistance with transferring with the use of a mechanical lift device by placing them at risk of having inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #32) observed for infection control. RN M failed to wear a gown and gloves while providing care for a resident on enhanced barrier precautions (EBP). This failure could lead to the resident being exposed to infections from other residents.

Inspectors wroteBased on interview and record review, the facility failed to conduct pre-employment nurse aide registry check to determine if the individual met competency evaluation requirements for 1 of 3 nurse aides (CNA A) whose personnel files were reviewed for registry verification. The facility failed to conduct a pre-employment nurse aide registry (NAR) check on CNA A. This failure could place residents at risk of being exposed to staff with histories of misconducts that were unemployable, increasing the risk for abuse or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #3) reviewed for enteral nutrition. 1. The facility failed to ensure Resident #3's head was elevated while his tube feeding was infusing. 2. The facility failed to date and time when Resident #3's bottle of liquid nutrition was hung. These failures could place residents at risk of aspiration (inhaling stomach contents into the lungs) and receiving nutrition fluid that is expired.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous medications. 1. The facility failed to ensure the dressing on Resident #1's PICC line (used to deliver medications and other treatments directly to the large central veins near heart) was changed timely. Resident #1 went without a dressing change for 10 days. 2. The facility failed to have orders for PICC line dressing changes and flushes. The failures could affect residents by placing them at risk for infections and cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #4) reviewed for infection control. CNA D failed to wear the appropriate PPE while providing care to Resident #4 who was on Enhanced Barrier Precautions. This failure could place residents at risk of being infected by staff in contact with other residents with infections.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure a safe and orderly discharge from the facility for one resident (Resident #1) of six residents reviewed for discharge planning. SW A and MDS Nurse B failed to ensure Resident #1 filed her NOMNC appeal by 08/10/24 to continue to stay at the facility. SW A and MDS Nurse B failed to ensure Resident #1 was given the second option to appeal to her Medicare Health plan, before she discharged [DATE]. SW A failed to follow-up with the DME Provider on 08/14/24 to give them additional documents needed to process the delivery of Resident #1's wheelchair. SW A failed to ensure Resident #1's correct address was given to the Home Health Care provider to ensure they could provide services to the town she lived in. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 2 of 3 residents (Residents #1 and #2) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #1 and Resident #2's catheter urine collection bags were kept off the floor and failed to ensure the collection bags had privacy covers. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent elopement for one (Resident #1) of five residents reviewed for elopements. The facility failed to ensure Resident #1, who had dementia and a history of wandering, had on a WanderGuard device as care planned to prevent elopement. This failure could place residents at risk of elopement or injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #3) of 5 residents reviewed for clinical records. The facility failed to ensure staff accurately documented on Resident #3's April 2024 Skilled Administration Record that she was being monitored for her behaviors. This failure could affect residents and place them at risk of inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #5) of five residents reviewed for call lights. The facility failed to ensure Resident #5's call light was accessible. This failure could place the residents at risk of falling, further injury, and unnecessary pain from not being able to call for help.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the Administrator for two (Residents #3 and #4) of four residents reviewed for abuse. The facility failed to ensure CNA Z immediately reported an allegation of abuse, on 02/03/24, when she observed Residents #3 and #4 were seen touching each other inappropriately, to the Administrator. This failure could place residents at risk of emotional, physical, and mental abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 3 of 7 residents (Residents #12, #31, and #132) reviewed for baseline care plans. The facility failed to ensure Residents #12, #31, and #132 had a baseline care plan, or conversely a comprehensive care plan, within 48 hours of admission. These failures could place the residents at risk of having their needs and preferences met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility provided food that was palatable, for one of one observed meal reviewed for dietary services. The facility failed to serve food that had a palatable texture during the lunch meal on 12/13/23. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a safe, clean, comfortable and homelike environment for 2 of 5 residents (Resident #37 and #49) reviewed for physical environment as evidenced by: The facility failed to ensure Resident #37 and #49's g-tube poles and floor were clean. These failures could place the three residents observed on g-tube feeding, at risk for the spread of infection and disease, a diminished quality of life and a diminished clean, homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for two (Resident #65 and #64) of four reviewed for feeding tubes. 1. The facility failed to follow physician's orders of providing Resident #65 with his 20 hours of feeding intake. 2. LVN F failed to provide Resident #64 her 10:00 AM bolus feeding as ordered by the physician. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #27) reviewed for insulin administration. LVN A failed to administer Resident #27's insulin according to physician's orders. This failure could place residents at risk for diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #227) reviewed for medication errors. ADON G failed to communicate an order change, which resulted in Resident #227 missing two days of antibiotic therapy. This failure could place residents at risk of their infections worsening, and extending their length of stay in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. Cook E failed to wear a hair restraint while in the facility's kitchen on 12/12/23. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for clinical records. The facility staff failed to document Resident #1's vitals and an assessment in the resident's EHR after the family had concerns for a change in condition. This failure could place all residents at risk for an impact to their treatment and health.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented and readily accessible for one of 5 residents (Resident #1) reviewed for clinical records. The facility failed to ensure funeral plans were documented in the EHR and accessible to staff at the time of Resident #1's death. This failure could place residents at risk for not having their decision for final rest and disposition honored.