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Nursing Facility

Fort Worth Transitional Care Center

Owned by: Government - Hospital district

Safety Pulse

AI-GENERATED FAMILY INSIGHTS

  • **Serious Safety Concerns:** Multiple citations for accident hazards and inadequate supervision suggest a risk of falls and injuries to residents.

  • **Questionable Care Practices:** Deficiencies in feeding tube management and lab services raise concerns about appropriate medical care and resident well-being.

  • **Care Plan Deficiencies:** Failure to develop and implement comprehensive care plans indicate a potential for unmet needs and compromised quality of life.

Note: This summary is generated from recently documented safety inspections and citations.

Regional Context

This Facility51
Fort Worth AVERAGE10.4

390% more violations than city average

Source: 3-year federal inspection history (CMS.gov)

Quick Stats

51Total Violations
136Certified Beds
Safety Grade
F
75/100 Score
F RATED
Safety Audit Result
Legal Consultation Available

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Violation History

CITATION DATEJanuary 1, 2026
F-TAG: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope & Severity (CMS Alpha)
Harm Level Detected
CITATION DATEJanuary 1, 2026
F-TAG: 0693

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Provide timely, quality laboratory services/tests to meet the needs of residents.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0692

Provide enough food/fluids to maintain a resident's health.

Provide enough food/fluids to maintain a resident's health.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Provide safe and appropriate respiratory care for a resident when needed.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0756

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0758

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0803

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0809

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0880

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0700

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0729

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0693

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0880

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0624

Prepare residents for a safe transfer or discharge from the nursing home.

Prepare residents for a safe transfer or discharge from the nursing home.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0558

Reasonably accommodate the needs and preferences of each resident.

Reasonably accommodate the needs and preferences of each resident.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0584

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0655

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0693

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0760

Ensure that residents are free from significant medication errors.

Ensure that residents are free from significant medication errors.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0610

Respond appropriately to all alleged violations.

Respond appropriately to all alleged violations.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope & Severity (CMS Alpha)
Harm Level Detected
CITATION DATEJanuary 1, 2026
F-TAG: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0565

Honor the resident's right to organize and participate in resident/family groups in the facility.

Honor the resident's right to organize and participate in resident/family groups in the facility.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0644

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0645

PASARR screening for Mental disorders or Intellectual Disabilities

PASARR screening for Mental disorders or Intellectual Disabilities

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0697

Provide safe, appropriate pain management for a resident who requires such services.

Provide safe, appropriate pain management for a resident who requires such services.

Scope & Severity (CMS Alpha)
Harm Level Detected
CITATION DATEJanuary 1, 2026
F-TAG: 0759

Ensure medication error rates are not 5 percent or greater.

Ensure medication error rates are not 5 percent or greater.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0760

Ensure that residents are free from significant medication errors.

Ensure that residents are free from significant medication errors.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope & Severity (CMS Alpha)
Potential for Harm
CITATION DATEJanuary 1, 2026
F-TAG: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope & Severity (CMS Alpha)
Potential for Harm

Regional Safety Benchmarking

City Performance (Fort Worth)AVG: 10.4

390% more citations than local average

"Comparative analysis is essential for identifying systemic neglect. Our benchmarks are updated monthly using raw CMS files."

Critical Evidence

Full Evidence Dossier

Documented history of neglect citations, staffing failures, and ownership risk profiles. Perfect for families, legal preparation, or professional due diligence.

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Open Guide
Source: CMS.gov / Medicare.gov
Dataset Sync: Feb 2026
Audit ID: NH-AUDIT-6E4CAAF0