Fort Worth Transitional Care Center

In the surveyor’s words

From the most serious findings on record at Fort Worth Transitional Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF695Apr 8, 2026

  Based 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… […]

• Immediate jeopardy, isolatedF684Jul 21, 2023

  Based on interviews and record reviews the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care received care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure LVN A followed proper procedure during wound care for Resident #1, and caused Resident #1's wound to start bleeding uncontrollably. This led to Resident #1 being transported to the hospital via EMS and Resident #1 was admitted to the hospital, required 4 blood transfusions due to blood loss, and was at risk of death. […]

• Immediate jeopardy, isolatedF689Apr 30, 2022

  Based on observations, record review and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Resident #1) of four residents reviewed for elopements. The facility failed to ensure Resident #1, who had dementia and a history of wandering, was provided with adequate supervision to prevent elopement when the resident was admitted on [DATE]. Due to the facility's WanderGuard alarm system not being audible at the nurses' station, the resident was able to elope 3.7 miles from the facility and was not found until approximately 15 hours later. An Immediate Jeopardy (IJ) was identified on 04/29/22 at 4:00 PM. […]

• Actual harm, patternF693Apr 8, 2026

  Based 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. […]

• Actual harm, isolatedF689Jun 24, 2025

  Based 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. […]