Inspection Reports for Fort Worth Transitional Care Center

The complaint investigation found that Resident #1 did not receive incontinence care for at least 4 hours, leading to urine soaking through bedding and clothing. Staff acknowledged difficulty in performing rounds every 2 hours, and the resident was dependent on staff for toileting and hygiene. The issue was substantiated with observations and interviews.

The facility failed to provide Resident #1 timely incontinence care for at least 4 hours on 10/23/25, resulting in the resident being soaked with urine through her brief, draw sheet, and bed sheets. This failure placed the resident at risk for decreased self-worth, skin breakdown, and infection. Staff interviews revealed challenges in completing rounds every 2 hours as required.

The facility failed to ensure that Resident #1's mattress overlay was properly secured, resulting in the resident falling out of bed. The overlay slid with the resident, preventing the built-in bolsters from functioning properly. The resident was evaluated and sent to the hospital at the family's request. The facility initiated staff training on proper use of mattress overlays and resident neglect.

The complaint investigation was substantiated. Resident #1 suffered an unwitnessed fall on 05/27/25, was found after three hours, and sustained a broken leg. Staff RN A and CNA B failed to monitor the resident appropriately; CNA B was terminated and RN A resigned. Resident #2's feeding pump was paused by CNA H and not restarted, risking nutritional harm. In-servicing was provided to staff following the incidents.

The facility failed to ensure adequate supervision to prevent accidents for Resident #1, who fell and was left on the floor for three hours resulting in a broken leg. Staff failed to monitor the resident as required, leading to disciplinary actions. Additionally, the facility failed to ensure proper care for Resident #2's enteral feeding, as a CNA paused the feeding pump and did not restart it or notify nursing staff, risking nutritional deficits.

The complaint investigation focused on Resident #1, whose family expressed concern about increased confusion and requested a urinalysis. The facility failed to collect the urine specimen despite multiple orders and attempts. The family called EMS to transport the resident to the hospital due to perceived increased confusion. The complaint was substantiated as the facility did not complete the ordered lab tests timely and did not adequately document or escalate the inability to collect the specimen.

The facility failed to complete Resident #1's lab order for a urinalysis with culture and sensitivity, which could have delayed treatment for laboratory abnormalities and clinical conditions. Interviews and record reviews revealed difficulties in obtaining the urine specimen, lack of documentation on specimen collection attempts, and failure to follow up with the physician for alternative collection methods such as straight catheterization. Resident #1 was transferred to the hospital due to increased confusion noted by family, but no infection was confirmed by hospital labs.

The complaint investigation revealed that Resident #22 had bedrails on his bed without an evaluation or order until the day before the surveyors questioned the facility. The Director of Nursing (DON) stated the hospice company brought a bed with bedrails without notifying the facility, and staff failed to notify the DON to complete the necessary evaluation and order. The DON emphasized the importance of having an order and evaluation to ensure bedrails are appropriate for the resident.

The facility failed to obtain a bed rail assessment and physician's order prior to installing bedrails for Resident #22, which could place residents at risk of entrapment or injury. The hospice company brought a bed with bedrails without notifying the facility, and the nursing department did not ensure an order and evaluation were in place before the bedrails were used.

The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents, inadequate supervision leading to a resident fall, failure to maintain accurate clinical records, failure to follow physician orders for weight monitoring and oxygen therapy, failure to ensure gradual dose reductions for psychotropic medications, failure to follow posted menus and serve meals timely, failure to maintain food service safety and infection control protocols, and failure to maintain an effective pest control program.

The complaint investigation found that CNA A was allowed to work starting 11/18/24 before completion of required background checks including nurse aide registry verification. The facility acknowledged miscommunication and procedural lapses in completing these checks prior to employment, increasing risk of abuse or neglect.

The facility failed to conduct a pre-employment nurse aide registry check for one nurse aide (CNA A) who began working before background checks were completed, potentially exposing residents to staff with histories of misconduct. Interviews and record reviews confirmed the lapse in completing required background checks prior to employment.

The facility was found deficient in multiple areas including improper care of residents with feeding tubes, failure to timely change PICC line dressings and lack of orders for dressing changes, and failure to implement proper infection control practices such as staff not wearing appropriate PPE for residents on Enhanced Barrier Precautions.

The complaint investigation revealed that Resident #1 was discharged home without proper home health services or DME, leading to unsafe conditions including lack of mobility support and incontinence care. The resident was hospitalized shortly after discharge due to these issues. The facility failed to ensure timely appeals were filed and did not coordinate discharge planning adequately. APS and hospital social workers confirmed these findings.

The facility failed to ensure Resident #1 filed a timely appeal to continue her stay, failed to provide proper discharge planning including coordination with home health and durable medical equipment (DME) providers, and discharged the resident without adequate support, resulting in the resident being unsafe at home and subsequently hospitalized. Interviews and record reviews confirmed multiple failures in discharge planning and coordination.

The facility failed to ensure that catheter urine collection bags for two residents were kept off the floor and had privacy covers, placing residents at risk for loss of dignity and potential infection. The facility also lacked a policy regarding indwelling Foley catheter care.

The facility failed to ensure Resident #5's call light was accessible, failed to timely report alleged abuse involving Residents #3 and #4, failed to ensure Resident #1 wore a WanderGuard device to prevent elopement, and failed to maintain accurate clinical documentation for Resident #3's behavior monitoring.

The complaint investigation revealed that Resident #27's insulin was administered late, and Resident #227 missed multiple antibiotic doses due to failure in communication and order processing by ADON G, who was subsequently terminated. The physician extended Resident #227's antibiotic therapy and stay due to the error.

The facility failed to provide pharmaceutical services ensuring accurate medication administration for two residents. One resident received insulin late, contrary to physician orders, and another missed two days of antibiotic therapy due to communication failures and staff not following order changes.

The facility was found deficient in multiple areas including failure to maintain a clean environment around feeding tubes, failure to develop baseline care plans within 48 hours of admission, failure to follow physician orders for feeding tube management and insulin administration, failure to prevent medication errors resulting in missed antibiotic doses, failure to provide palatable food, and failure to enforce hair restraint use in the kitchen.

The complaint investigation found that Resident #1's family was concerned about the resident's toes turning black and requested care and information. The nurse did not document the assessment or vitals after the family raised concerns, and the resident was taken to the hospital by ambulance. The Director of Nursing and Medical Doctor confirmed the lack of documentation despite the assessment being performed. The family was anxious and wanted the resident sent to the hospital, and the facility staff failed to properly document the care provided.

The facility failed to document Resident #1's vitals and assessment in the electronic health record (EHR) after the family expressed concerns about the resident's right foot condition. Interviews with staff revealed that although an assessment and vitals were reportedly taken, they were not documented in the EHR, posing a risk to resident care and safety.

The facility failed to ensure that medical records were complete and accessible, specifically lacking documentation of funeral plans in the electronic health record (EHR) for Resident #1. This failure could risk residents not having their final disposition wishes honored. Interviews revealed no centralized documentation or policy for funeral plans in the facility.

The complaint involved Resident #1 not receiving scheduled showers on multiple days. Interviews with Resident #1, nursing staff, and CNA confirmed missed showers due to staffing shortages. The Director of Nursing acknowledged the failure and the risks associated with missed showers. Additionally, a complaint-related observation found an unlocked wound care cart, which was addressed by staff.

The facility failed to provide showers to Resident #1 on scheduled days (Tuesday, Thursday, and Saturday), placing the resident at risk for hygiene decline and skin breakdown. Additionally, the facility failed to secure drugs and biologicals properly, as a nurse wound care/treatment cart was found unlocked and unattended.

The complaint involved allegations of abuse during wound care of Resident #1, including failure to report the incident timely and failure to investigate the abuse. The resident suffered severe bleeding during wound vac change, was sent to the hospital, and required blood transfusions. The facility initially did not report the incident as abuse and did not initiate an investigation promptly.

The facility failed to timely report suspected abuse related to wound care of Resident #1, failed to thoroughly investigate the abuse allegations, and failed to provide appropriate treatment and care according to professional standards. This resulted in Resident #1 suffering severe hemorrhaging during wound vac care, requiring hospital transfer and multiple blood transfusions. Immediate Jeopardy was identified but later removed after corrective actions were implemented.

The facility failed to ensure sharps containers in 17 resident rooms and nurse medication carts were changed out before being overfilled, posing a risk of exposure to bloodborne pathogens. Additionally, the facility failed to maintain accurate narcotic medication administration records for one resident, risking potential medication errors.

The facility was found deficient in multiple areas including failure to provide private meeting space for resident council meetings, inaccurate PASRR screenings and incomplete assessments, inadequate pain management for a resident, high medication error rates, failure to ensure residents were free from significant medication errors, improper medication storage and labeling, and failure to store, prepare, and serve food according to professional standards.