Richland Hills Rehab: Fall Prevention Failure - TX
Weeks later, the mat was not there.
The resident, identified in inspection records only as Resident 22, used a mechanical lift for transfers and had a habit of repositioning himself in his wheelchair. The assistant director of nursing, referred to in the report as the ADON, told inspectors that the repositioning created a risk of him sliding out of the chair. After he fell on May 13, 2026, the ADON said she personally took responsibility for getting the mat and placing it on the wheelchair. Aides were then supposed to confirm it was in place before every transfer.
That was the plan. Both the ADON and the director of nursing described it the same way when inspectors interviewed them on May 28, 2026. The DON said the mat was needed to prevent injury. The DON said the ADON was responsible for providing it, placing it, and making sure staff knew to check for it daily.
At 2:00 that same afternoon, inspectors watched Resident 22 get taken to his room for incontinence care. Staff used the mechanical lift to move him to bed. Inspectors looked at his wheelchair.
No mat.
The DON, when interviewed an hour later, acknowledged what that meant. If the ADON had not placed the mat, the DON said, Resident 22 was at risk of sliding out of his wheelchair and being injured.
The facility's own fall prevention policy, revised just three months earlier in February 2026, states that after any resident fall, staff must investigate the circumstances and take action to reduce the chance of another fall and minimize potential for injury. The mat was that action. It was the entire response to his fall. And on the day inspectors arrived, it was missing from the chair he was transferred into and out of every day.
The inspection was filed as a complaint. Inspectors rated the harm level as minimal or potential for actual harm, with few residents affected. That classification reflects the fact that Resident 22 had not fallen again by the time inspectors arrived. It does not reflect what would have happened if he had repositioned himself in a wheelchair with no mat and nothing to stop him from sliding out.
What the inspection captures is something more routine than a dramatic failure and, in some ways, harder to fix. A plan existed. Both supervisors knew it. The DON could describe, in precise terms, who was responsible for what and why it mattered. The ADON had agreed to handle it personally. Somewhere between that agreement and the afternoon of May 28, the mat never made it onto the chair, and nobody caught it.
Richland Hills Rehabilitation and Healthcare Center is located in Fort Worth. The inspection was conducted on May 28, 2026.
Resident 22 was transferred to his bed that afternoon without the mat. When the transfer was done, he was moved back to his wheelchair. The inspection report does not say whether the mat was added after inspectors noted its absence. It does not say whether anyone told Resident 22 why the thing meant to keep him safe had not been there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Richland Hills Rehabilitation and Healthcare Cente from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
Richland Hills Rehabilitation and Healthcare Cente in Fort Worth, TX was cited for violations during a health inspection on May 28, 2026.
Weeks later, the mat was not there.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.