Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fort Worth Transitional Care Center during CMS and state inspections, most recent first.
A resident with a trach was sent to the hospital after labored breathing, and hospital staff found the inner cannula fully clogged with dry secretions and a foul odor, requiring trach replacement in the ED. Another resident with a trach was observed with thick secretions, no Ambu bag in the room, delayed nursing response to the call light, and suctioning performed without checking SpO2 before, during, or after the procedure and with improper suction technique. A family member was also suctioning the trach without training.
Feeding tube care and medication administration were not provided appropriately for two residents with G-tubes. One resident was sent to the hospital with a clogged, dirty, malfunctioning tube and abdominal distention, and hospital staff reported the tube had not been cared for. Another resident’s meds were observed being force-flushed through the G-tube by an LVN who said she did not know how the tube worked and pushed the meds when gravity flow was difficult, despite facility policy requiring gravity administration and no force-flushing.
Unlabeled and improperly stored medications were found in medication carts, including a resident’s opened lorazepam stored unrefrigerated, an opened Lantus pen without a resident name label, and unlabeled bottles of nystatin and a tube of ammonium lactate. RN D stated she was unaware of the refrigeration requirement for lorazepam and acknowledged the labeling issues, while the ADON and DON stated nurses and medication aides were responsible for proper labeling and storage.
Failure to Complete Baseline Care Plan Within 48 Hours: A resident admitted with osteomyelitis of the L ankle and foot, DM2, and acute kidney failure did not have a baseline care plan completed within 48 hours of admission. The EMR showed the plan was overdue, and the Interim DON confirmed there was no evidence the admitting nurse initiated and completed the required baseline care plan.
Incomplete Care Plan for Bed Rail Mobility Intervention: A resident with multiple diagnoses, including stroke history, morbid obesity, anxiety, depression, schizoaffective disorder, and functional quadriplegia, had an active order for one or both bed rails for mobility assistance and repositioning. The comprehensive care plan did not include the bed rail intervention, and the MDSC acknowledged it was omitted as an oversight. The resident reported using the rails daily to help reposition herself, and the DON stated MDS nurses complete and review care plans for accuracy.
A resident with debility, functional quadriplegia, hemiplegia, and vascular dementia had side rails on both sides of the bed for positioning and mobility, but the Side-Rail Use Assessment was incomplete and lacked a signature/date. Although a consent form was signed and the chart showed a discontinued MD order stating the resident no longer had side rails, the resident was still observed with half bedrails in place and said she used them daily. Interviews with the MDSC, MD, DON, and LVN confirmed the facility expected quarterly assessments and a current MD order for bed rail use.
Medication handling and administration errors were identified for two residents. One resident’s controlled pain medication was found in a damaged blister pack that had been taped closed, and staff said they were responsible for checking blister packs during narcotic counts. Another resident with sepsis, MDRO, and UTI had an IV ertapenem dose hanging even though the saline was finished and the medication remained in the vial; the assigned LVN did not notice the medication had not been properly administered. The DON stated the IV medication should have been reconstituted before use and that taped controlled-medication blister packs were not appropriate.
A resident with significant physical and cognitive impairments, fully dependent on staff for incontinence care, was left in urine-soaked bedding for at least seven hours due to staff not performing required two-hourly rounds. Staff interviews and observations confirmed that the resident was not checked or changed as per care plan and facility policy, resulting in the resident being found wet through her brief, sheets, and gown.
A resident with significant physical and cognitive impairments, including left-sided weakness and total dependence on staff, experienced a fall when her mattress overlay was not properly secured, allowing both the overlay and the resident to slide off the bed. Staff interviews and documentation confirmed the overlay had been left with an unsecured strap, and required fall risk assessments were not completed as per facility policy.
A resident with a history of falls, moderate cognitive impairment, and multiple medical conditions was left unsupervised for several hours after an unwitnessed fall, resulting in a leg fracture. Staff failed to perform required two-hour rounding, and the resident's call light was not within reach, leading to a delay in assistance and injury.
A resident who was entirely dependent on staff and received all nutrition via a gastric tube did not receive prescribed enteral nutrition when a CNA paused the feeding pump for incontinence care and failed to restart it or notify a nurse. The facility lacked a policy on gastric tube management, and the ADON confirmed that CNAs were not authorized to operate feeding pumps.
A resident with multiple medical conditions did not receive a physician-ordered urinalysis with C&S due to staff's inability to collect a urine specimen and lack of escalation or documentation of the issue. Nursing staff passed the order between shifts without success, and alternative collection methods were not pursued or communicated to the physician. The facility did not meet its policy requirements for timely laboratory services, resulting in the ordered test not being completed.
The facility failed to implement comprehensive care plans for residents, omitting physician orders for weekly weight monitoring and necessary transfer assistance. This led to unmonitored weight fluctuations and a fall incident during a transfer, highlighting significant care planning deficiencies.
A resident with severe cognitive impairment and multiple medical conditions experienced a significant weight loss due to the facility's failure to conduct weekly weight checks as ordered. The resident's care plan required supervision with eating and monitoring for swallowing difficulties, but the facility did not consistently monitor her weight or food intake. The physician and dietician were not informed of the weight loss, preventing timely interventions. The facility's oversight placed the resident at risk of further health complications.
The facility failed to provide accurate respiratory care for two residents. One resident received 3 liters of oxygen instead of the ordered 2 liters, with no documentation or order for the change. Another ventilator-dependent resident was not repositioned every two hours as ordered, potentially affecting secretion management. The DON was unaware of these issues, and the facility lacked a policy on following physician orders and oxygen use.
A facility failed to act on a pharmacist's recommendation for a gradual dose reduction of a resident's medications, Duloxetine and Zolpidem. The resident, with a history of anxiety, depression, and psychotic disorder, continued receiving the medications without adjustments. Interviews revealed a lack of clarity and responsibility among staff regarding follow-up on pharmacy recommendations.
The facility did not follow the posted lunch menu, serving different items than those listed, which led to residents being unaware of what they would be served. The Head of the dietary department cited supplier issues for the substitutions, and the absence of the DM did not affect the service. However, the lack of communication about menu changes left residents uncertain about their meals.
The facility failed to serve lunch at the scheduled time, resulting in delays and resident dissatisfaction. Lunch was supposed to be served between 12:00 PM and 1:00 PM, but service began at 1:05 PM, with the last resident served at 2:00 PM. Residents expressed hunger and frustration due to the delay. The absence of the DM did not affect the service, but the Head of the kitchen acknowledged the delay. The facility's policy requires meals to be served at regular times, which was not followed.
The facility failed to maintain food safety standards in the 3rd floor's satellite kitchen. Drinks were not covered, risking contamination, and steamtable compartments contained debris, compromising food hygiene. Staff were unaware of the requirement to cover drinks, and the cleanliness of steamtables was neglected, violating the facility's meal service policy.
The facility's pest control program was ineffective, leading to a roach infestation in the Third Floor dining room and resident rooms. Despite monthly treatments, residents and staff reported ongoing issues with roaches, causing discomfort and frustration. The Maintenance Director and Administrator relied on external pest control services and staff documentation, but the measures taken were insufficient to resolve the problem.
A resident dependent on staff for transfers was improperly assisted by a CNA, resulting in the resident being lowered to the floor. The incident was not documented or reported to the necessary parties, including the family and physician, as required by the facility's policy. The resident, with a history of mobility issues and other medical conditions, reported a minor skin injury. The facility's failure to document and notify placed the resident at risk.
A resident experienced a fall during a transfer, which was not documented by the responsible LVN. The resident, who had multiple health conditions and was at risk for falls, was lowered to the floor by an aide. The LVN did not report the incident to the DON, physician, or family, leading to incomplete clinical records and potential risk of injury.
A facility failed to maintain an effective infection control program when an RN did not follow Enhanced Barrier Precautions (EBP) for a resident with a gastric tube. Despite clear postings, the RN administered medications without wearing the required gown, only using gloves. The RN admitted to forgetting due to nervousness, and the DON confirmed the necessity of gown and gloves for high-contact activities as per facility policy.
A resident with severe cognitive impairment had bed rails installed without prior assessment or a physician's order. The hospice company installed the bed rails without notifying the facility, and staff failed to report their presence. The necessary evaluation and order were completed only after surveyors raised questions, potentially placing the resident at risk of entrapment or injury.
The facility failed to conduct pre-employment background checks for a CNA before she began working, leading to her working 60 hours without the necessary checks being completed. This oversight was due to miscommunication and a lapse in following the facility's hiring policy, which requires background checks to be completed before a new hire can start work. The failure to adhere to this policy could potentially expose residents to staff with histories of misconduct.
A facility failed to maintain proper protocols for a resident receiving enteral nutrition, including not elevating the head of the bed during feeding and not labeling the nutrition bottle with the date and time it was hung. These actions could risk aspiration and expired nutrition fluid.
A resident with a PICC line did not receive timely dressing changes, going 10 days without a change, due to a lack of physician orders and documentation. The dressing was observed to be dirty, and staff admitted to not checking or changing it as required. The DON was unaware of the issue, and the facility's policy on PICC lines was not provided.
A facility failed to maintain an effective infection control program when a CNA did not use the required PPE while caring for a resident with a urinary catheter, wound, and feeding tube. Despite a posting indicating Enhanced Barrier Precautions, the CNA only wore gloves, contrary to policy requiring a gown and gloves. Interviews confirmed the oversight and the importance of PPE to prevent infection spread.
A resident was discharged from a facility without proper discharge planning, resulting in a lack of necessary medical equipment and home health services. The resident, who had multiple medical conditions and was non-weight bearing, was left at home without a wheelchair or adequate support, leading to a hospital readmission. The facility failed to ensure timely filing of the NOMNC appeal and did not coordinate effectively with DME and home health providers.
Two residents with catheters were found with their catheter bags on the floor and uncovered, compromising hygiene and dignity. One resident expressed concern about the lack of privacy, while the other noted infrequent emptying of the bag. Staff interviews revealed a lack of adherence to proper catheter care practices, and the facility lacked a specific policy on catheter care.
A resident with dementia and a history of wandering was found without a WanderGuard device, despite care plans and orders requiring daily checks and monitoring. The device was found among personal items, and multiple dates showed lapses in monitoring documentation. The facility's policy on elopement prevention was not followed, leading to the deficiency.
The facility failed to maintain accurate clinical records for a resident with dementia, as staff did not document required behavior monitoring on multiple dates. Interviews revealed that it was the responsibility of the nurse on duty to document behaviors, but chart audits found numerous gaps in the records.
The facility failed to ensure a resident's call light was accessible, despite the resident's severe cognitive impairment and physical disabilities. Observations showed the call light was out of reach, and staff interviews confirmed it should have been within reach at all times, as per facility policy.
A CNA observed inappropriate touching between two residents but did not report the incident to the Administrator immediately, delaying the investigation and response. The incident involved a female resident with severe cognitive impairment and a male resident with mild cognitive impairment and quadriplegia. Despite staff training, the incident was not reported until two days later.
Respiratory/Tracheostomy Care and Suctioning Deficiencies
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents with tracheostomies. One resident had diagnoses including dysphagia and respiratory failure, had physician orders for daily inner cannula changes, trach collar and tubing changes, suctioning every shift for copious secretions, and trach care with normal saline and dressing changes. On 04/05/2026, the resident was noted to have labored breathing and was suctioned before being transferred to the hospital. In the hospital, staff documented that the inner cannula was fully clogged with dry secretions, the trach had a foul smell, and the resident coughed up blood when the inner cannula was removed. Hospital staff replaced the trach in the emergency room. A second resident with a tracheostomy and physician orders for trach changes and suctioning every shift was observed with thick mucus, audible rattling and gurgling, and phlegm on the trach tie. During the survey, the resident did not have an Ambu bag in the room when the surveyor first observed the room. The resident’s family member was suctioning the trach, and the family member stated she had not been trained on trach care. When the surveyor activated the call light, a CNA turned it off and left the room, and the resident continued coughing with thick secretions until nursing staff arrived later. When nursing staff entered the room, the nurse changed the trach tie and gauze but did not assess oxygen saturation before suctioning, did not hyperoxygenate the resident, and did not check oxygen saturation before, during, or after suctioning. The nurse used suctioning technique that included applying suction while advancing the catheter and using a back-and-forth motion. The nurse stated she was not aware of the physician order for suctioning as needed for copious secretions and could not identify the Ambu bag or its purpose. The facility’s respiratory therapist stated that staff provided respiratory care such as suctioning and trach care, and that dried hard secretions and foul odor would indicate improper trach care.
Feeding Tube Care and Medication Administration Failures
Penalty
Summary
The facility failed to ensure appropriate care and safe feeding practices for two residents receiving enteral nutrition through gastrostomy tubes. Resident #71 had diagnoses including dysphagia, aphasia, and respiratory failure, and her care plan and physician orders included tube feeding with monitoring for aspiration, tube dysfunction, abdominal distention, constipation, nausea/vomiting, and dehydration. Her active order also required residual checks every shift, with the physician to be called if residual was greater than 100 cc. Resident #71 was transferred to the hospital after family concerns about shortness of breath and abdominal distention. Hospital records documented that she arrived with a clogged and malfunctioning G-tube, and the hospital physician noted abdominal distention in the setting of PEG obstruction/complication. Hospital staff reported the G-tube valve had no caps, was dirty, and was occluded with dried brownish substance, and attempts to declog it were unsuccessful. The hospital case manager stated the resident was admitted with complications of a trach and clogged G-tube, and the hospital RN stated the tube was not being cared for by the nursing home. Resident #8 also had a feeding tube and was ordered NPO with Osmolite 1.5 tube feeding and water flushes before and after medication administration. During observation, an LVN was seen force-flushing 7 of 13 medications individually through the G-tube. The LVN stated it was her first time working with the resident, did not know how the G-tube worked, and pushed the medications because gravity flow was difficult. The DON stated G-tube medications should be administered by gravity and that if the tube was not patent, attempts should be made to declog it and, if unsuccessful, the medication should be held and the MD notified. The facility policy also stated not to force-flush the tube or use a rigid object to clear a clog.
Unlabeled and Improperly Stored Medications in Medication Carts
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles on the 300 short hall and 300 long hall medication carts. On observation of the 300 short hall nurses medication cart, Resident #13’s opened lorazepam oral concentrate 2 mg/mL was stored unrefrigerated in the medication cart, and two bottles of nystatin 100,000 units/gram and a tube of ammonium lactate 12% were present without prescription labels. During interview, RN D stated she was not aware lorazepam was supposed to be refrigerated and acknowledged the nystatin and ammonium lactate did not have patient labels. She stated the risk of not refrigerating a medication that required refrigeration was loss of potency and ineffectiveness, and that unlabeled medication created a risk for medication error. On observation of the 300 long hall medication cart, an opened Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML was stored in the cart without a resident name label. RN D stated she was not aware the Lantus lacked the required label and said all medications were supposed to have a pharmacy label. She stated having insulin in the medication cart without the proper label could result in administration to the wrong resident and may result in hospitalization. The ADON and DON stated nurses and medication aides were responsible for ensuring medications were properly labeled and stored per manufacturer recommendations, and both confirmed the risk of unlabeled medications was medication error.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #119 within 48 hours of admission. Review of the resident’s face sheet showed she was a [AGE]-year-old female admitted with diagnoses including chronic multifocal osteomyelitis of the left ankle and foot, type 2 diabetes mellitus, and acute kidney failure. Review of the electronic medical record on 04/08/26 showed no evidence that a baseline care plan had been completed, and a notification indicated the baseline care plan was overdue. During an interview on 04/08/26 at 12:17 PM, the Interim DON stated she was responsible for overseeing completion of baseline care plans and that the admitting nurse was required to initiate the plan, with review to ensure completion within 48 hours of admission. She confirmed there was no evidence that Resident #119 had a baseline care plan completed within 48 hours of admission. The facility’s Baseline Care Plan policy, dated 06/06/25, stated the baseline care plan would be developed within 48 hours of a resident’s admission and include the minimum healthcare information necessary to properly care for the resident.
Incomplete Care Plan for Bed Rail Mobility Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #14 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #14’s MDS assessment reflected diagnoses including cerebral infarction, atrophy, morbid obesity, anxiety disorder, depression, schizoaffective disorder, and functional quadriplegia, with a BIMS score of 14 indicating intact cognitive impairment. The resident’s comprehensive care plan, initiated on 11/27/2023, did not address the use of one or both bed rails as an intervention for mobility assistance. Record review showed an active physician order dated 04/06/2026 with a start date of 02/07/2026 authorizing the use of one or both bed rails every shift for mobility assistance and repositioning. During interview, the resident stated she used the side rails every day, mostly to help reposition herself, and said they were very helpful. The MDSC stated the side rail use should have been added to the care plan and that its omission was an oversight. The DON stated there are two MDS nurses who complete the Baseline and Comprehensive Care Plans and that the MDSC reviews care plans for accuracy.
Incomplete Bed Rail Assessment and No Current Order for Side Rail Use
Penalty
Summary
The facility failed to ensure correct use of bed rails and failed to assess one resident for risk of entrapment related to bed rail use. Resident #7 was admitted with diagnoses including age-related physical debility, functional quadriplegia, hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, and vascular dementia. Her quarterly MDS showed a BIMS score of 13, indicating minimal cognitive impairment, and she required partial to moderate assistance with bed mobility. Section P of the MDS indicated she used a bed rail daily, and her care plan identified that she used side rails to both sides of the bed for positioning and mobility. Record review showed the resident’s Side-Rail Use Assessment Form was incomplete because Section C, Recommendations, was not completed and had no signature or date. The Nursing Side Rail Evaluation was completed, and a Bed Rails/Device Informed Consent form was signed, but the record review also showed the physician’s order for rails to both sides of the bed had a start date of 01/12/26 and an end date of 04/02/26, with the order status listed as discontinued and notes stating, “No longer has side rails.” Despite this, observation on 04/06/26 found the resident in her room with half bedrails on both sides of her bed, and the resident stated she used the bedrails every day to reposition herself in bed. During interviews, the MDSC stated quarterly bed rail assessments were completed by the DON or ADON and that missing signatures were the responsibility of the person completing the form. The MD stated staff must have a physician’s order to start or discontinue bed rail use. The DON stated side rail evaluations should be completed at admission, quarterly, or as needed, and that residents with bed rails needed a current doctor’s order. Facility policy stated bed rails may be considered a physical restraint and that a physician’s order alone was not sufficient to warrant use of a physical restraint.
Medication Handling and Administration Errors
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, administering, and disposition of controlled drugs for two residents. For one resident with chronic pain syndrome and low back pain, the active order was for Acetaminophen-Codeine 300-30 mg every 4 hours as needed for breakthrough pain. During observation of the medication cart, the resident’s Tylenol 300/30 mg controlled medication was found with a damaged blister bubble and the capsule still inside, and the blister pack had been secured with tape. The RN stated she had not noticed the damaged blister before it was brought to her attention and said staff were responsible for inspecting blister packs at every shift change during narcotic counts. For another resident with severe cognitive impairment, sepsis, MDRO, and UTI, the active order was for Ertapenem Sodium 1 gram IV at bedtime for infection related to sepsis. During observation, the resident’s IV medication was found hanging on the IV pole, the normal saline solution was completed, but the medication remained in the vial. The resident stated he had received the IV medication the previous night. The LVN assigned to the resident stated she did not notice the medication was still in the vial and thought it had been properly administered because the saline was completed. The DON stated the IV medication should have been reconstituted with normal saline before administration and that the narcotic blister pack should not have been taped once the seal was broken. The DON also stated the pill should have been disposed of with two nurses witnessing the disposal. Facility documentation reflected a medication error for the IV medication. The report also notes the facility’s policies for medication administration, parenteral administration, and controlled substance disposal.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was fully dependent on staff for activities of daily living, including incontinence care, was not provided timely assistance. The resident, who had multiple diagnoses such as hemiplegia, seizure disorder, anxiety disorder, depression, bipolar disorder, and cerebral palsy, was found to be soaked with urine through her brief, draw sheet, and bed sheets. The care plan for this resident required staff to check and assist with toileting every two hours, but on the day in question, the resident had not been changed for at least seven hours, with the last incontinence care provided around 4:00 AM and the next care not occurring until after 11:00 AM. Observations and interviews revealed that the resident's room had a strong smell of urine, and the resident herself reported being wet and needing to be changed. Staff interviews confirmed that the resident was fully incontinent and dependent on staff for care, and that it was not normal for her to be found in such a condition. The CNA assigned to the resident admitted to not having checked on her yet during the shift, citing difficulties in performing two-hourly rounds due to workload and assignment changes. The RN and ADON both stated that staff were expected to check on residents at least every two hours, and acknowledged that the resident should have been checked and changed more frequently. Facility policy required perineal care to be provided during routine baths and as needed to promote cleanliness, comfort, and prevent infection and skin breakdown. Despite this, the resident was left in urine-soaked bedding for an extended period, which was confirmed by multiple staff members and direct observation. No skin issues were noted at the time, but staff recognized that such lapses in care placed the resident at risk for adverse outcomes.
Failure to Secure Mattress Overlay Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was provided with an environment free from accident hazards, specifically by not properly securing the resident's mattress overlay. The resident, who had a history of stroke with left-sided weakness, dysphasia, aphasia, and required a tracheostomy, was totally dependent on staff for all activities of daily living and was assessed as a high fall risk. Despite care plan interventions requiring safe and proper positioning in bed on her air mattress, the mattress overlay was not properly secured, as one of the straps was left unfastened. This oversight resulted in the resident sliding off the bed along with the unsecured mattress overlay, as captured in video footage provided by the family. The incident occurred while the resident was lying in bed and subsequently fell headfirst onto a fall mat beside the bed. Nursing documentation confirmed the resident was found on the floor with the overlay, and no immediate injuries were observed. The family was notified and requested hospital evaluation, where the resident was diagnosed with a urinary tract infection and returned to the facility the same day. Interviews with staff revealed that the overlay had previously been found unsecured and that it was the responsibility of nurses and CNAs to ensure overlays were properly attached. The DON acknowledged that the required fall risk assessments were not completed as scheduled or after the fall event. The facility's policy required fall risk assessments on admission, quarterly, and after any fall, but these were not conducted as required for this resident.
Failure to Provide Adequate Supervision and Accident Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and assistance devices to prevent accidents for a resident with a history of repeated falls, moderate cognitive impairment, and multiple medical diagnoses including liver failure and dementia. The resident required staff assistance with activities of daily living and used a walker for transfers. The care plan identified the resident as being at risk for falls and included interventions such as keeping the bed in the lowest position and ensuring the call light was within reach. Despite these interventions, the resident experienced an unwitnessed fall during the early morning hours, which was not discovered for approximately three hours. On the night of the incident, the resident attempted to transfer from her bed to her chair using her walker and fell at approximately 3:20 AM. The resident's door was closed at her request, making it difficult for staff to hear her calls for help. The resident was not found until 6:20 AM by a nurse making morning rounds. During this time, the resident was heard calling for help on video footage, but staff did not respond. The last documented check by a CNA was at 2:30 AM, and the CNA did not check on the resident again during the remainder of the shift, citing a desire not to wake the resident. The facility's expectation was for staff to round on residents at least every two hours, but this was not followed. As a result of the fall, the resident sustained a fracture to her lower leg and required non-weight bearing status for four weeks. The incident was unwitnessed, and the resident was left on the floor for an extended period before being discovered. Staff interviews confirmed that rounding protocols were not adhered to, and the resident's call light was not within reach at the time of the fall. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to ensure adequate supervision and accident prevention measures for a resident at high risk for falls.
Failure to Ensure Proper Management of Enteral Feeding Pump
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) paused a resident's enteral feeding pump to provide incontinence care and failed to restart the pump or notify a nurse to do so after the care was completed. The resident, a female with a history of stroke, inability to swallow requiring a gastric tube, and a tracheostomy, was entirely dependent on staff for activities of daily living and received all nutrition via her gastric tube as ordered by her physician. The physician's order specified a continuous feeding regimen using a stationary pump. During observation, the CNA paused the feeding pump before providing care and left the pump paused upon exiting the room, proceeding to round on other residents. The assistant director of nursing (ADON) confirmed that CNAs were not permitted to start, stop, or pause feeding pumps, as the formula was considered a medication. The facility did not have a policy addressing gastric tube feedings or management at the time of the incident.
Failure to Obtain Ordered Laboratory Services for a Resident
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered for a resident who had multiple complex medical conditions, including a history of urinary tract infection, cognitive impairment, and pressure ulcers. Despite physician orders for a urinalysis with culture and sensitivity (C&S) on two separate occasions, there was no evidence in the clinical record that a urine specimen was collected or that lab results were obtained for either order. Nursing staff documented difficulty in collecting a urine sample due to the resident's incontinence and fluctuating ability to cooperate, but did not escalate the issue or document all attempts as required. Interviews with nursing staff and facility leadership revealed that the order for urinalysis was passed between shifts without successful collection, and alternative methods such as straight catheterization were not pursued. The DON and ADON acknowledged that the nurses should have contacted the physician for further instructions or to obtain an order for straight catheterization, but this was not done. The nurses also failed to consistently document their attempts to collect the specimen or to communicate the ongoing issue during daily clinical meetings as expected by facility policy. The resident was ultimately transferred to the hospital by family due to concerns of increased confusion, and hospital records indicated that no urinary infection was found. The facility's policy required timely provision or procurement of laboratory services when ordered, but this was not met in the resident's case, as the ordered urinalysis was not completed and the process for addressing collection difficulties was not followed.
Deficiencies in Care Planning and Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, which resulted in deficiencies in addressing specific medical orders and needs. For four residents, the care plans did not include physician orders for weekly weight monitoring, despite the presence of conditions such as feeding tube requirements and cognitive impairments. This oversight was evident in the records of residents who experienced weight fluctuations, indicating a lack of adherence to prescribed monitoring protocols. Additionally, the facility did not create a care plan for a resident requiring a mechanical lift for transfers, which led to an incident where the resident fell during a transfer attempt. The resident, who had a history of mobility issues and was dependent on staff for transfers, was not adequately care planned for the use of a mechanical lift, resulting in a fall and minor injury. The resident's care plan lacked specific interventions for safe transfer assistance, which contributed to the incident. The Director of Nursing acknowledged the failure to weigh residents as ordered and indicated a need for staff education on following physician orders. The lack of comprehensive care planning placed residents at risk for potential weight loss, nutritional decline, and injury during transfers, highlighting significant gaps in the facility's care planning processes.
Failure to Monitor Resident's Weight Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in a significant weight loss of 7.75%. The resident, an elderly female with severe cognitive impairment and multiple medical conditions including anemia, high blood pressure, end-stage renal disease, dysphagia, and non-Alzheimer's dementia, was not weighed weekly as per physician orders. The missed weight checks occurred over several weeks, and the facility did not alert the physician or dietician about the resident's weight loss, which could have prompted timely interventions. The resident's care plan indicated a need for supervision with eating and monitoring for signs of swallowing difficulties. Despite these requirements, the facility did not consistently monitor the resident's weight or food intake, leading to a lack of awareness of her declining nutritional status. Interviews with staff revealed that the responsibility for weighing residents was not clearly executed, with aides and nurses failing to ensure the resident was weighed according to schedule. This oversight contributed to the resident's unmonitored weight loss. The physician and dietician were not informed of the resident's weight loss, which hindered their ability to address the issue promptly. The dietician noted that the resident had been on a puree diet, which she disliked, and had recently transitioned to a mechanical soft diet. However, the lack of consistent weight monitoring meant that the dietician was unaware of the resident's weight decline until it was observed during a survey. The facility's failure to follow its weight monitoring policy placed the resident at risk of further weight loss and associated health complications.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide accurate respiratory care for two residents requiring oxygen therapy. For one resident, the facility did not have accurate physician orders for oxygen use. The resident was observed receiving 3 liters of oxygen via nasal cannula, despite the physician's order for 2 liters. The Licensed Vocational Nurse (LVN) confirmed the discrepancy and noted that there was no documentation or order for the increased oxygen level. The Director of Nursing (DON) was unaware of the change and emphasized the importance of following physician orders, highlighting a lack of communication and documentation regarding the resident's oxygen needs. Another resident, who was ventilator-dependent, was not repositioned every two hours as ordered by the physician. Observations revealed that the resident remained in the same position for extended periods, which could hinder the expectoration of secretions. An LVN expressed difficulty in repositioning the resident due to the need to disconnect the ventilator, and admitted to not performing passive range of motion exercises due to a lack of training. The DON acknowledged that repositioning should not be avoided due to difficulty and was unaware of the specific repositioning order. These deficiencies in respiratory care could place residents at risk for inadequate oxygen delivery and potential complications. The facility lacked a policy on following physician orders and oxygen use, which contributed to the oversight in care for these residents.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to act upon drug regimen irregularities reported by the Pharmacist Consultant for a resident. The Pharmacist Consultant recommended a gradual dose reduction for the resident's Duloxetine and Zolpidem, but this recommendation was not communicated to the resident's primary care physician. This oversight could place residents at risk for adverse consequences and a decline in their condition. The resident in question was a female with a history of anxiety disorder, depression, and psychotic disorder, who was receiving antipsychotics, antidepressants, and hypnotics. Despite the Pharmacist Consultant's recommendation for a dose reduction, there was no documentation of an attempt or a clinical contraindication by the physician. The resident continued to receive the medications as ordered without any adjustments. Interviews with facility staff revealed a lack of clarity and responsibility regarding the follow-up on pharmacy recommendations. The Assistant Director of Nursing (ADON) was unsure of the process and frequency for considering gradual dose reductions (GDRs), and the Director of Nursing (DON) acknowledged the oversight and the need for improvement. The facility's policy required drug regimen reviews to be conducted by the pharmacist, with recommendations communicated to the attending physician, but this process was not effectively implemented in this case.
Failure to Follow Posted Menu
Penalty
Summary
The facility failed to adhere to the posted lunch menu on January 28, 2025, which was supposed to include roast beef, dill potatoes, red cabbage, wheat bread, margarine, ice cream, coffee or tea, and a garnish parsley sprig. Instead, the meal served consisted of beef tips, rosemary potatoes, green cabbage, a roll, and pears. This discrepancy was observed during the lunch service and was confirmed through interviews with both residents and staff. A resident expressed that the menu was not usually posted or followed, leading to uncertainty about what meals would be served. The Head of the dietary department acknowledged that substitutions were made due to the unavailability of certain items from the supplier, and the absence of the Dietary Manager (DM) on that day did not disrupt the lunch service. However, the Head admitted that the residents were not informed of the menu changes until they received their meals, which did not match the posted menu. The DM later confirmed that the menu should be posted daily and any changes should be communicated to the residents to avoid misleading them. The failure to follow the menu could affect all residents by not informing them of what they would be served, potentially impacting their meal satisfaction and dietary preferences.
Delayed Meal Service Leads to Resident Dissatisfaction
Penalty
Summary
The facility failed to ensure that residents received meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs and preferences. On the day in question, lunch was scheduled to be served between 12:00 PM and 1:00 PM, but the service was delayed. Observations revealed that the dietary staff began taking food temperatures at 12:40 PM, and one of the food items, rosemary potatoes, was not at the correct temperature and had to be reheated. As a result, the lunch service did not begin until 1:05 PM, and the last resident was served at 2:00 PM. Interviews with residents indicated dissatisfaction with the meal service timing, with one resident expressing that lunch was often served late and another stating they were starving due to the delay. The Head of the kitchen acknowledged the delay and mentioned that the absence of the Dietary Manager (DM) did not interrupt the lunch service, although the meal was not served on time. The DM, upon return, expressed surprise at the delay and noted that such delays could impact residents' medication schedules, therapy, and conditions like diabetes. The facility's policy requires meals to be served at regular times, with at least a four-hour interval between meals, which was not adhered to in this instance.
Food Safety Deficiencies in Satellite Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the 3rd floor's satellite kitchen, specifically in the areas of drink coverage and steamtable cleanliness. Observations revealed that drinks leaving the kitchen were not covered, which could lead to contamination. Interviews with CNAs indicated they were unaware of the requirement to cover drinks, and the Head of the kitchen acknowledged that lids were supposed to be provided but was unsure if they were available on the day in question. The Dietary Manager (DM) confirmed that drinks should be covered to prevent cross-contamination. Additionally, the facility did not ensure the cleanliness of the steamtable compartments before placing food in them. Observations showed cloudy water with debris in the steamtable compartments, which were used to serve various food items. The Head of the kitchen admitted to not checking the water before placing food containers on the line and acknowledged that the water should have been clean to prevent contamination. The DM stated that the steamtables should be drained and cleaned every night to maintain hygiene and prevent debris from contaminating the food. The facility's policy on meal service, which requires the cleaning and sanitizing of food-contact surfaces and equipment, was not followed. This policy mandates that all multi-use utensils and food-contact surfaces be cleaned and sanitized prior to each use, and at scheduled intervals during food preparation. The failure to adhere to these procedures could potentially expose residents to food-borne illnesses and contamination, as the facility did not maintain the required standards for food safety and hygiene.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the Third Floor dining room and resident rooms. Observations and interviews revealed that roaches were seen along the baseboards in the dining room while residents were present, and residents reported seeing roaches in their rooms and personal belongings. Despite monthly pest control treatments documented in the facility's records, residents expressed that the measures taken were ineffective, and they felt uncomfortable and frustrated with the ongoing pest issue. Interviews with staff, including a CNA and the Maintenance Director, confirmed the presence of roaches in resident rooms and common areas. The CNA reported the issue in the pest control logbook, while the Maintenance Director acknowledged seeing roaches but stated that pest control was the responsibility of an external company. The Administrator, who had not personally observed roaches, relied on the pest control company’s reports and staff documentation to address pest issues. The facility's pest control policy outlined regular service schedules and communication protocols, but the ongoing presence of roaches indicated a failure in effectively implementing these measures.
Failure to Ensure Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, identified as Resident #194, who was dependent on two or more staff for transfers. On a specific date, a CNA failed to safely transfer the resident, resulting in the resident being lowered to the floor. This incident was not documented or reported to the necessary parties, including the family, physician, and facility leadership, as required by the facility's Fall Prevention Program policy. Resident #194, a cognitively intact male with a BIMS score of 15, had functional limitations and was dependent on staff for transfers. His medical history included conditions such as abnormalities of gait and mobility, muscle wasting, lack of coordination, Type 1 Diabetes, stroke, and renal insufficiency. The resident's care plan indicated a moderate risk for falls, but it did not specify the level of assistance required for transfers. After the incident, the resident reported a skin injury to his elbow, which was observed to be healing, and he was subsequently transferred using a mechanical lift with two staff members. Interviews with facility staff revealed that the incident was not initially considered a fall by the LVN on duty, who did not document or report it. The DON later confirmed that the incident should have been reported and documented according to protocol. The facility's policy defines a fall as an event where an individual unintentionally comes to rest on the ground, and a near miss is also considered a fall if the resident would have fallen without intervention. The lack of documentation and notification placed the resident at risk of injury and his family at risk of not being informed about his health status.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who experienced a fall. The incident involved a male resident who was dependent on staff for transfers and had multiple health conditions, including Type 1 Diabetes, stroke, and renal insufficiency. The resident was at moderate risk for falls due to deconditioning and gait/balance problems. Despite these risks, the facility did not document a fall that occurred during a transfer. The incident was first brought to attention when the resident's family member inquired about a fall the resident had mentioned. Upon investigation, it was revealed that the resident was lowered to the floor by an aide during a transfer to bed. LVN B, who was responsible for the resident during the shift, did not document the fall or report it to the necessary parties, including the DON, physician, or family. LVN B did not consider the lowering to the ground as a fall and therefore did not follow the facility's protocol for documentation and notification. The lack of documentation and communication placed the resident at risk of injury, as the staff was not properly informed of the resident's change in status. The DON confirmed that LVN B did not follow the facility's protocol, which required documentation and notification of any changes in a resident's condition. This failure to document and communicate the fall could potentially affect other residents who require assistance with transfers, as it may lead to inaccurate or incomplete clinical records.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a registered nurse (RN) who did not adhere to the required Enhanced Barrier Precautions (EBP) for a resident. The resident was on EBP due to having a gastric tube, which necessitated the use of a gown and gloves during direct care activities to prevent the transmission of infections. Despite the clear posting outside the resident's room indicating the need for such precautions, the RN administered medications via the resident's gastric tube and a subcutaneous injection while only wearing gloves, omitting the required gown. During an interview, the RN admitted to forgetting to wear the necessary personal protective equipment (PPE) due to nervousness caused by the presence of a surveyor. The Director of Nursing (DON) confirmed that all staff are required to wear a gown and gloves when providing direct care to residents on EBP, especially when performing high-contact activities such as medication administration via a gastric tube. The facility's policy on EBP, dated April 2024, outlines the necessity of these precautions to reduce the transmission of multi-drug-resistant organisms.
Failure to Follow Bed Rail Procedures
Penalty
Summary
The facility failed to follow proper procedures before installing bed rails for a resident, leading to a deficiency. The resident, who was admitted to the facility with severe cognitive impairment and other medical conditions, had bed rails installed without prior assessment or a physician's order. The resident's admission records and care plan did not initially reflect the use of bed rails, and the necessary evaluation and order were only completed after surveyors inquired about the situation. The Director of Nursing (DON) acknowledged that the bed rails were installed by the hospice company without notifying the facility, and the staff failed to notice and report the presence of the bed rails. This oversight resulted in the absence of an evaluation and order to ensure the appropriateness of the bed rails for the resident, potentially placing the resident at risk of entrapment or injury. The DON admitted that the nursing department was responsible for ensuring the proper procedures were followed, including obtaining an order and conducting an evaluation before the installation of bed rails.
Failure to Conduct Pre-Employment Background Checks for CNA
Penalty
Summary
The facility failed to conduct a pre-employment nurse aide registry check to determine if CNA A met competency evaluation requirements before starting work. CNA A was hired on 11/18/24, but the necessary background checks, including the Texas Criminal History Registry, EMR, and NAR checks, were not completed until after she began working. The HRC, responsible for completing these checks, acknowledged that CNA A was placed on the schedule due to a miscommunication and oversight, leading to her working 60 hours before the checks were finalized. The Interim Administrator and DON confirmed that CNA A started working with residents without the necessary background checks being completed. The facility's hiring policy requires background checks to be completed before a new hire can officially begin work, but this was not adhered to in CNA A's case. The failure to complete these checks before CNA A started working could potentially expose residents to staff with histories of misconduct, increasing the risk of abuse or neglect.
Failure to Maintain Proper Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications associated with tube feeding. Specifically, the facility did not maintain the required elevation of the resident's head while the tube feeding was infusing. Observations revealed that the resident was lying flat on his back, contrary to the care plan's directive to keep the head of the bed elevated to 45 degrees during feeding. This oversight was confirmed through interviews with facility staff, who acknowledged the necessity of maintaining head elevation to prevent aspiration. Additionally, the facility did not adhere to proper protocols for labeling the resident's liquid nutrition. The bottle of liquid nutrition was observed without a date or time indicating when it was hung, which is essential for ensuring the nutrition fluid is not expired. Interviews with the LVN and DON confirmed that the bottle should be labeled with the time, date, rate, and name, and that it is only good for 24 hours. These lapses in care could place residents at risk of aspiration and receiving expired nutrition fluid.
Failure in PICC Line Management and Documentation
Penalty
Summary
The facility failed to ensure the timely and appropriate administration of intravenous (IV) fluids for a resident, specifically in the management of a peripherally inserted central catheter (PICC) line. The resident, a male with a history of acute osteomyelitis and methicillin-resistant Staphylococcus aureus (MRSA) infection, did not have his PICC line dressing changed for 10 days. There were no physician orders for PICC line dressing changes and flushes, and the facility's treatment administration records lacked documentation of any dressing changes. The resident's care plan addressed IV medication but did not include interventions for PICC line dressing changes. Observations revealed that the PICC line dressing was intact but dirty, and the resident confirmed it had not been changed since being applied at the hospital. A Licensed Vocational Nurse (LVN) admitted to not checking the dressing date and acknowledged the dressing should have been changed. The Director of Nursing (DON) expected staff to change PICC dressings every seven days but was unaware of the oversight. The facility's policy on PICC lines was not provided upon request, and there was no evidence of staff training on PICC line management.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA D, who did not adhere to the required Enhanced Barrier Precautions while providing care to a resident. The resident, a male with cerebral palsy, seizures, cognitive communication deficit, and difficulty swallowing, was admitted with a urinary catheter, a wound to his hip, and a feeding tube. Despite the posting on the resident's door indicating the need for a gown and gloves, CNA D only wore gloves during incontinence care, which was not in compliance with the facility's policy. Interviews with CNA E and the ADON confirmed the oversight, with CNA E admitting to not reading the posting and acknowledging the importance of Enhanced Barrier Precautions in preventing infection spread. The ADON and DON reiterated the requirement for staff to wear appropriate PPE, including gowns and gloves, for residents on Enhanced Barrier Precautions. The facility's policy, dated earlier in the year, clearly outlined the need for such precautions for residents with wounds or indwelling medical devices, regardless of known infection status.
Failure in Discharge Planning and Coordination
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge of a resident. The resident, who was cognitively intact with a BIMS score of 13, had multiple medical conditions including lower extremity weakness, hypertension, diabetes, and a recent fracture. Despite these conditions, the facility did not ensure that the resident's NOMNC appeal was filed in time, resulting in the resident being discharged without the necessary support and equipment. The social worker and MDS nurse did not follow up adequately with the DME provider to ensure the delivery of the resident's wheelchair, nor did they provide the correct address to the home health care provider. As a result, the resident was discharged without essential medical equipment and home health services. The resident was left at home without a wheelchair, unable to move or attend to personal needs, and was eventually taken to the hospital due to the unsafe discharge. Interviews with various staff members and family revealed a lack of communication and coordination in the discharge planning process. The facility's discharge planning policy was not effectively implemented, leading to the resident being discharged without the necessary support systems in place. This oversight placed the resident at risk of health decline and necessitated readmission to a healthcare facility.
Deficiency in Catheter Care and Resident Dignity
Penalty
Summary
The facility failed to provide appropriate care for two residents with catheters, leading to deficiencies in maintaining catheter hygiene and privacy. Resident #1, a male with moderate cognitive impairment and multiple health conditions, including renal insufficiency and obstructive uropathy, was observed with his catheter bag on the floor without a privacy cover. This was noted during an observation when the resident was in his room, and the catheter bag was not handled by the CNA who delivered his lunch tray. The resident expressed a desire for his catheter bag to be covered, especially after a recent urinary tract infection. Similarly, Resident #2, a female with severe cognitive impairment and a suprapubic catheter due to neurogenic bladder, was found with her catheter bag full, on the floor, and uncovered. The resident expressed a need for more frequent emptying of the bag, as it sometimes felt like it was backing up. Interviews with the CNAs revealed a lack of attention to ensuring the catheter bags were covered and off the floor, which is crucial for maintaining resident dignity and preventing infection. The facility's staff, including CNAs and LVN, acknowledged the importance of keeping catheter bags covered and off the floor to prevent infection and maintain resident dignity. However, there was a lack of adherence to these practices, as evidenced by the observations and interviews. The Director of Nursing confirmed the expectation for all catheter bags to be covered and properly positioned, but the facility did not have a specific policy regarding indwelling Foley catheter care.
Failure to Ensure Resident Wore WanderGuard Device
Penalty
Summary
The facility failed to ensure that Resident #1, who had dementia and a history of wandering, was wearing a WanderGuard device as care planned to prevent elopement. Resident #1, a [AGE] year-old female with moderate cognitive impairment and a history of wandering, was observed without the WanderGuard device on her ankle. The device was found among personal items on the resident's bedside table, with signs of tampering and disrepair. Despite the care plan and orders specifying the need for daily checks and monitoring of the WanderGuard, there were multiple dates in April 2024 where no entries were made in the Monitoring Administration Record (MAR) for the day shift, indicating lapses in monitoring and documentation by the staff. During an interview, the Licensed Vocational Nurse (LVN) on duty claimed to have checked the WanderGuard that morning, but upon inspection, the device was not on Resident #1. The LVN then educated the resident about the necessity of wearing the WanderGuard and initiated one-on-one monitoring to prevent exit-seeking behaviors. The Director of Nursing (DON) confirmed that residents with a BIMS score below 13 required a WanderGuard and that the nursing staff were responsible for ensuring the device was intact and functioning. The DON acknowledged that failure to complete the monitoring placed residents at risk of exiting the building and potential harm. The Administrator also confirmed that all residents with a BIMS score below 13 should have WanderGuards and that the facility had additional security measures, such as secured elevators, to prevent elopement. However, the Administrator was unaware that Resident #1 did not have the WanderGuard on and acknowledged the risk of residents exiting the building unattended. The facility's policy on Elopements and Wandering Residents emphasized the need for adequate supervision and systematic monitoring to prevent accidents, which was not adhered to in this case, leading to the deficiency.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident reviewed for clinical records. Specifically, the facility did not ensure that staff accurately documented on the resident's Skilled Administration Record that she was being monitored for her behaviors. The resident, a female with dementia and severe cognitive impairment, had a care plan that required monitoring for inappropriate behavior towards staff and other residents. However, multiple dates in April 2024 had no entries documenting this monitoring, indicating a lapse in record-keeping by the staff on duty during those shifts. Interviews with staff, including an LVN and the Interim DON, revealed that it was the responsibility of the nurse on duty to document any behaviors during their shift on the resident's MAR/TAR. The Interim DON acknowledged finding numerous gaps in the residents' MARs/TARs during chart audits, emphasizing that this documentation is a legal requirement to ensure proper monitoring. The facility's policy mandates that licensed staff document all assessments, observations, and services provided in the resident's medical record at the time of service or no later than the shift in which the care occurred. The failure to adhere to this policy resulted in incomplete and inaccurate clinical records for the resident in question.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a critical aspect of accommodating resident needs and preferences. Resident #5, a male with severe cognitive impairment and multiple physical disabilities, was observed on two separate occasions with his call light out of reach, underneath his roommate's bed. This resident is dependent on staff for most activities of daily living and is at moderate risk for falls due to his impaired mobility and functional quadriplegia. Despite the care plan specifying that the call light should be within reach, staff did not adhere to this requirement, potentially compromising the resident's ability to call for assistance when needed. During an interview, the Interim DON confirmed that it is the responsibility of CNAs and nurses to ensure that call lights are within reach of residents at all times. The facility's policy on call light accessibility also mandates that call lights should be within reach and secured as needed. However, observations and interviews revealed that this policy was not followed, as evidenced by the call light being out of reach for Resident #5. This failure could lead to significant risks for the resident, including falls and unmet needs for assistance.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the Administrator for two residents reviewed for abuse. Specifically, a CNA observed inappropriate touching between two residents but did not report the incident to the Administrator immediately. The incident occurred on a Saturday, but the Administrator was not informed until the following Monday, delaying the investigation and response to the alleged abuse. Resident #3, a female with severe cognitive impairment and a history of physical behaviors towards others, was observed touching Resident #4, a male with mild cognitive impairment and quadriplegia. Resident #4 was seen grabbing Resident #3's breast and later placing her hand on his crotch area. The CNA who witnessed the incident reported it to a nurse on duty, but the nurse did not escalate the report to the Administrator immediately. The delay in reporting was confirmed through interviews with the CNA, the nurse, and the Administrator. The Administrator emphasized that all staff are trained to report any allegations of abuse immediately to ensure timely investigation and intervention. Despite this training, the incident was not reported until two days later, highlighting a failure in the facility's abuse reporting protocol.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 756 citations issued within 25 miles in the last 12 months — including the 37 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Downtown Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 10 | 0 |
| Dfw Nursing & Rehab | 0.8 mi | ★★★★★ | 13 | 4 |
| Arbor Lake Nursing & Rehabilitation, Llc | 0.8 mi | ★★★★★ | 2 | 0 |
| James L West Center For Dementia Care | 0.9 mi | ★★★★★ | 0 | 0 |
| The Stayton At Museum Way | 0.9 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Fort Worth Transitional Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.